Healthcare Provider Details

I. General information

NPI: 1013994078
Provider Name (Legal Business Name): NORTHERN BOULEVARD IMAGING, MDPC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 09/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16425 NORTHERN BLVD
FLUSHING NY
11358-2646
US

IV. Provider business mailing address

PO BOX 18005
HAUPPAUGE NY
11788-8805
US

V. Phone/Fax

Practice location:
  • Phone: 718-358-4075
  • Fax: 718-358-4076
Mailing address:
  • Phone: 631-517-8000
  • Fax: 631-893-1923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ALLEN ROTHPEARL
Title or Position: SENIOR PARTNER
Credential: MD
Phone: 631-517-8006