Healthcare Provider Details

I. General information

NPI: 1003625294
Provider Name (Legal Business Name): PRONEURODIAGNOSTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2025
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 NORTHERN BLVD UNIT 366
GREENVALE NY
11548-4015
US

IV. Provider business mailing address

37 NORTHERN BLVD UNIT 366
GREENVALE NY
11548-4015
US

V. Phone/Fax

Practice location:
  • Phone: 516-353-1735
  • Fax:
Mailing address:
  • Phone: 516-353-1735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204R00000X
TaxonomyElectrodiagnostic Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084D0003X
TaxonomyDiagnostic Neuroimaging (Psychiatry & Neurology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code246ZE0500X
TaxonomyEEG Specialist/Technologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name: MR. ALI RODRIGUEZ
Title or Position: OWNER
Credential:
Phone: 516-353-1735