Healthcare Provider Details

I. General information

NPI: 1154512267
Provider Name (Legal Business Name): PROFESSIONAL DIAGNOSTIC SONOGRAPHY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 10/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6545 MYRTLE AVE
GLENDALE NY
11385-7028
US

IV. Provider business mailing address

6545 MYRTLE AVE
GLENDALE NY
11385-7028
US

V. Phone/Fax

Practice location:
  • Phone: 718-386-8137
  • Fax: 718-386-7908
Mailing address:
  • Phone: 718-386-8137
  • Fax: 718-386-7908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246XS1301X
TaxonomySonography Specialist/Technologist Cardiovascular
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2471V0105X
TaxonomyVascular Sonography Radiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name: MR. GERARDO PALERMO
Title or Position: MANAGER
Credential: RDMS, RDCS, RVT
Phone: 718-386-8137