Provider Demographics
NPI:1700234358
Name:CHURCH-MCDONALD MEDICAL DIAGNOSTIC PLLC
Entity Type:Organization
Organization Name:CHURCH-MCDONALD MEDICAL DIAGNOSTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHALLONIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-399-5085
Mailing Address - Street 1:486 MCDONALD AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11432
Mailing Address - Country:US
Mailing Address - Phone:352-399-5085
Mailing Address - Fax:866-402-3481
Practice Address - Street 1:486 MCDONALD AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11432
Practice Address - Country:US
Practice Address - Phone:352-399-5085
Practice Address - Fax:866-402-3481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY239768261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain