Provider Demographics
NPI:1962856450
Name:INTEGRATED MEDICAL INTERVENTIONAL DIAGNOSTICS PC
Entity Type:Organization
Organization Name:INTEGRATED MEDICAL INTERVENTIONAL DIAGNOSTICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:HASIB
Authorized Official - Middle Name:MIKAEL
Authorized Official - Last Name:SARIJ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-336-8659
Mailing Address - Street 1:1111 BROAD HOLLOW RD 110 SUITE 114
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735
Mailing Address - Country:US
Mailing Address - Phone:516-336-8659
Mailing Address - Fax:516-253-2141
Practice Address - Street 1:1111 BROAD HOLLOW RD 110 SUITE 114
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735
Practice Address - Country:US
Practice Address - Phone:516-336-8659
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
229328163WP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0000XNursing Service ProvidersRegistered NursePain ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02549791Medicaid
WXWPR1Medicare PIN
I07147Medicare UPIN