Provider Demographics
NPI:1467794354
Name:RENAISSANCE MEDICAL IMAGING PC
Entity Type:Organization
Organization Name:RENAISSANCE MEDICAL IMAGING PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:DENISE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:646-713-2955
Mailing Address - Street 1:5106 VERNON BLVD
Mailing Address - Street 2:STE 204
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101
Mailing Address - Country:US
Mailing Address - Phone:646-713-2955
Mailing Address - Fax:877-888-7955
Practice Address - Street 1:5106 VERNON BLVD
Practice Address - Street 2:STE 204
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101
Practice Address - Country:US
Practice Address - Phone:646-713-2955
Practice Address - Fax:877-888-7955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-19
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00922725Medicaid