Provider Demographics
NPI:1619231578
Name:ADVANCED DIAGNOSTIC IMAGING PLLC
Entity Type:Organization
Organization Name:ADVANCED DIAGNOSTIC IMAGING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SASAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AZAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-662-6424
Mailing Address - Street 1:13848 ELDER AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-4066
Mailing Address - Country:US
Mailing Address - Phone:718-321-7100
Mailing Address - Fax:718-321-7115
Practice Address - Street 1:13848 ELDER AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-4066
Practice Address - Country:US
Practice Address - Phone:718-321-7100
Practice Address - Fax:718-321-7115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY194192261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY617541Medicare PIN