Provider Demographics
NPI:1528218294
Name:ACTIVE MEDICAL DIAGNOSTICS PC
Entity Type:Organization
Organization Name:ACTIVE MEDICAL DIAGNOSTICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MOSOMILLO
Authorized Official - Suffix:
Authorized Official - Credentials:DO, NMM
Authorized Official - Phone:631-661-6611
Mailing Address - Street 1:422C GREAT EAST NECK ROAD
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704
Mailing Address - Country:US
Mailing Address - Phone:631-661-6611
Mailing Address - Fax:631-661-5504
Practice Address - Street 1:422C GREAT EAST NECK ROAD
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704
Practice Address - Country:US
Practice Address - Phone:631-661-6611
Practice Address - Fax:631-661-5504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service