MEDICARE: C K MEDICAL DIAGNOSTIC SERVICES 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	:	1508240623
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	C K MEDICAL DIAGNOSTIC SERVICES PC

Provider Business Mailing Address
First Line	:	2407 E 23RD ST
Second Line	:	SUITE A
City	:	BROOKLYN
State	:	NY
Zip	:	11235-2510
Country	:	US
Telephone Number	:	718-648-1300
Fax Number	:	718-648-3100

Provider Business Practice Location Address
First Line	:	2407 E 23RD ST
Second Line	:	SUITE A
City	:	BROOKLYN
State	:	NY
Zip	:	11235-2510
Country	:	US
Telephone Number	:	718-648-1300
Fax Number	:	718-648-3100

Authorized Official
Title or Position	:	DIRECTOR
Name	:	KEVIN CUSTIS
Credential	:	M.D.
Telephone Number	:	718-648-1300

Provider Enumeration Date	:	07/18/2015
Last Update Date	:	07/18/2015

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