Healthcare Provider Details

I. General information

NPI: 1740527993
Provider Name (Legal Business Name): INTEGRATED MEDICAL DIAGNOSTIC SERVICES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2013
Last Update Date: 08/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2171 JERICHO TPKE SUITE 100
COMMACK NY
11725-2937
US

IV. Provider business mailing address

PO BOX 13023
HAUPPAUGE NY
11788-0535
US

V. Phone/Fax

Practice location:
  • Phone: 877-646-2228
  • Fax: 877-922-3329
Mailing address:
  • Phone: 877-646-2228
  • Fax: 877-922-3329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number180648-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE CLANCY
Title or Position: EXECUTIVE ADMINISTRATOR
Credential:
Phone: 877-646-2228