Provider Demographics
NPI:1497771687
Name:MIDDLE VILLAGE DIAGNOSTIC IMAGING PC
Entity Type:Organization
Organization Name:MIDDLE VILLAGE DIAGNOSTIC IMAGING PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEMO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-605-2395
Mailing Address - Street 1:6243 WOODHAVEN BLVD
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3731
Mailing Address - Country:US
Mailing Address - Phone:718-507-4700
Mailing Address - Fax:
Practice Address - Street 1:6243 WOODHAVEN BLVD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3731
Practice Address - Country:US
Practice Address - Phone:718-507-4700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02705411Medicaid
NY02705411Medicaid