Provider Demographics
NPI:1952758807
Name:ROOSEVELT CARDIO VASCULAR DIAGNOSTIC, P.C.
Entity Type:Organization
Organization Name:ROOSEVELT CARDIO VASCULAR DIAGNOSTIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:RYBSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:718-942-9355
Mailing Address - Street 1:3751 90TH ST # A
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-7829
Mailing Address - Country:US
Mailing Address - Phone:718-942-9355
Mailing Address - Fax:
Practice Address - Street 1:37-51 A 90TH ST
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7936
Practice Address - Country:US
Practice Address - Phone:718-942-9355
Practice Address - Fax:718-285-0399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-20
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2532881261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2532881OtherLICENSE