Healthcare Provider Details

I. General information

NPI: 1003097270
Provider Name (Legal Business Name): EAST QUEENS MEDICAL DIAGNOSTIC SERVICES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2007
Last Update Date: 11/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23011 LINDEN BLVD
CAMBRIA HEIGHTS NY
11411-1851
US

IV. Provider business mailing address

230-11 LINDEN BLVD
CAMBRIA HEIGHTS NY
11411-1851
US

V. Phone/Fax

Practice location:
  • Phone: 718-276-3400
  • Fax: 718-276-3402
Mailing address:
  • Phone: 718-276-3400
  • Fax: 718-276-3402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number179357
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number116260
License Number StateNY

VIII. Authorized Official

Name: DR. CLINTON J SEWELL
Title or Position: PRESIDENT
Credential: M.D.
Phone: 718-276-3400