Healthcare Provider Details

I. General information

NPI: 1710904701
Provider Name (Legal Business Name): ENDOSCOPIC DIAGNOSTIC & TREATMENT CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 08/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 BAY RIDGE PKWY
BROOKLYN NY
11209-3310
US

IV. Provider business mailing address

560 BAY RIDGE PKWY
BROOKLYN NY
11209-3310
US

V. Phone/Fax

Practice location:
  • Phone: 718-748-5219
  • Fax: 718-439-4873
Mailing address:
  • Phone: 718-748-5219
  • Fax: 718-439-4873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number7001122R
License Number StateNY

VIII. Authorized Official

Name: MRS. LISA DOWD
Title or Position: OFFICE MANAGER
Credential:
Phone: 718-748-5219