Provider Demographics
NPI:1013994078
Name:NORTHERN BOULEVARD IMAGING, MDPC
Entity Type:Organization
Organization Name:NORTHERN BOULEVARD IMAGING, MDPC
Other - Org Name:QUEENS OPEN MRI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTHPEARL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-517-8006
Mailing Address - Street 1:PO BOX 18005
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-8805
Mailing Address - Country:US
Mailing Address - Phone:631-517-8000
Mailing Address - Fax:631-893-1923
Practice Address - Street 1:16425 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358-2646
Practice Address - Country:US
Practice Address - Phone:718-358-4075
Practice Address - Fax:718-358-4076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02532070Medicaid
NY01671Medicare ID - Type Unspecified