MEDICARE: SPRINGFIELD RADIOLOGY IMAGING PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

General Provider Information

NPI Number	:	1083950281
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPRINGFIELD RADIOLOGY IMAGING PC

Provider Business Mailing Address
First Line	:	6829 SPRINGFIELD BLVD
Second Line	:
City	:	BAYSIDE
State	:	NY
Zip	:	11364-2632
Country	:	US
Telephone Number	:	718-279-4200
Fax Number	:	718-279-0020

Provider Business Practice Location Address
First Line	:	6829 SPRINGFIELD BLVD
Second Line	:
City	:	BAYSIDE
State	:	NY
Zip	:	11364-2632
Country	:	US
Telephone Number	:	718-279-4200
Fax Number	:	718-279-0020

Authorized Official
Title or Position	:	MD
Name	:	AYOOB KHODADADI
Credential	:
Telephone Number	:	718-279-1300

Provider Enumeration Date	:	12/17/2012
Last Update Date	:	12/17/2012

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