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
State | License ID | Taxonomies |
---|---|---|
NY | 239768 | 261QP3300X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QP3300X | Ambulatory Health Care Facilities | Clinic/Center | Pain |