Basic Information
| Provider Information | |||||||||
| NPI: | 1366490104 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED RADIOLOGICAL IMAGING-ASTORIA PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2002 | ||||||||
| Address2: | |||||||||
| City: | EAST SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130574502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153625285 | ||||||||
| FaxNumber: | 3154452936 | ||||||||
| Practice Location | |||||||||
| Address1: | 2916 ASTORIA BLVD | ||||||||
| Address2: | |||||||||
| City: | ASTORIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 111021742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182045800 | ||||||||
| FaxNumber: | 7187214572 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 02/05/2015 | ||||||||
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| AuthorizedOfficialLastName: | TARTELL | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7182045800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 02442868 | 05 | NY | MEDICAID |