MEDICARE: CARDIOCARE 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	207RC0000X	Cardiovascular Disease Physician

General Provider Information

NPI Number	:	1962703017
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARDIOCARE IMAGING PC

Provider Business Mailing Address
First Line	:	2310 EASTCHESTER RD
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10469-5911
Country	:	US
Telephone Number	:	718-519-6340
Fax Number	:

Provider Business Practice Location Address
First Line	:	2310 EASTCHESTER RD
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10469-5911
Country	:	US
Telephone Number	:	718-519-6340
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DONALD C WALLERSON
Credential	:	M.D.
Telephone Number	:	718-519-6340

Provider Enumeration Date	:	11/05/2010
Last Update Date	:	11/05/2010

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