Provider Demographics
NPI:1760435291
Name:MEDICAL DIAGNOSTIC IMAGING PLLC
Entity Type:Organization
Organization Name:MEDICAL DIAGNOSTIC IMAGING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:GROSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-471-2848
Mailing Address - Street 1:14 RAYMOND AVE
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-2312
Mailing Address - Country:US
Mailing Address - Phone:845-471-2848
Mailing Address - Fax:845-790-1180
Practice Address - Street 1:14 RAYMOND AVE
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-2312
Practice Address - Country:US
Practice Address - Phone:845-471-2848
Practice Address - Fax:845-790-1180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY186503174400000X
261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWEN841Medicare PIN