Provider Demographics
NPI:1467761957
Name:LEADING EDGE MEDICAL DIAGNOSTIC MD PC
Entity Type:Organization
Organization Name:LEADING EDGE MEDICAL DIAGNOSTIC MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GENE
Authorized Official - Middle Name:
Authorized Official - Last Name:KHODAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-562-4545
Mailing Address - Street 1:290 BROADWAY STE 1
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-5301
Mailing Address - Country:US
Mailing Address - Phone:845-562-4545
Mailing Address - Fax:845-562-4555
Practice Address - Street 1:290 BROADWAY
Practice Address - Street 2:STE 1
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-5301
Practice Address - Country:US
Practice Address - Phone:845-562-4545
Practice Address - Fax:845-562-4545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-30
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty