Provider Demographics
NPI:1760693337
Name:MEDICAL DIAGNOSTIC GROUP LAB
Entity Type:Organization
Organization Name:MEDICAL DIAGNOSTIC GROUP LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LAB DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLIOTT
Authorized Official - Middle Name:T
Authorized Official - Last Name:FRIEDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-342-5681
Mailing Address - Street 1:210 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-4038
Mailing Address - Country:US
Mailing Address - Phone:845-342-5681
Mailing Address - Fax:845-342-0470
Practice Address - Street 1:210 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-4038
Practice Address - Country:US
Practice Address - Phone:845-342-5681
Practice Address - Fax:845-342-0470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYCLIA33D0653745291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW19711Medicare PIN