Provider Demographics
NPI:1699853606
Name:DIAGNOSTIC X-RAY SERVICE, INC.
Entity Type:Organization
Organization Name:DIAGNOSTIC X-RAY SERVICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:WUERSTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-459-6280
Mailing Address - Street 1:1769 W 26TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16508-1256
Mailing Address - Country:US
Mailing Address - Phone:800-446-9729
Mailing Address - Fax:814-459-6386
Practice Address - Street 1:2828 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-1722
Practice Address - Country:US
Practice Address - Phone:814-459-6280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01676219Medicaid
NY02996936Medicaid