Provider Demographics
NPI:1003097270
Name:EAST QUEENS MEDICAL DIAGNOSTIC SERVICES, PC
Entity type:Organization
Organization Name:EAST QUEENS MEDICAL DIAGNOSTIC SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:J
Authorized Official - Last Name:SEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-276-3400
Mailing Address - Street 1:230-11 LINDEN BLVD
Mailing Address - Street 2:
Mailing Address - City:CAMBRIA HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11411-1851
Mailing Address - Country:US
Mailing Address - Phone:718-276-3400
Mailing Address - Fax:718-276-3402
Practice Address - Street 1:23011 LINDEN BLVD
Practice Address - Street 2:
Practice Address - City:CAMBRIA HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11411-1851
Practice Address - Country:US
Practice Address - Phone:718-276-3400
Practice Address - Fax:718-276-3402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1162602085B0100X
NY179357207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB80483Medicare UPIN
NYE50314Medicare UPIN