Provider Demographics
NPI:1134233497
Name:PRESTIGE PHYSICIANS SERVICES, PLLC
Entity type:Organization
Organization Name:PRESTIGE PHYSICIANS SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:DIAMOND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:914-755-6812
Mailing Address - Street 1:164 WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:CORNWALL
Mailing Address - State:NY
Mailing Address - Zip Code:12518-1329
Mailing Address - Country:US
Mailing Address - Phone:914-755-6812
Mailing Address - Fax:845-565-4941
Practice Address - Street 1:164 WILLOW AVE
Practice Address - Street 2:
Practice Address - City:CORNWALL
Practice Address - State:NY
Practice Address - Zip Code:12518
Practice Address - Country:US
Practice Address - Phone:845-565-1771
Practice Address - Fax:845-565-4941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2018-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05174598Medicaid