Healthcare Provider Details

I. General information

NPI: 1952601668
Provider Name (Legal Business Name): IDEAL IDTF SERVICES OF NEW YORK, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2010
Last Update Date: 10/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4394 BROADWAY
NEW YORK NY
10040-4002
US

IV. Provider business mailing address

4394 BROADWAY
NEW YORK NY
10040-4002
US

V. Phone/Fax

Practice location:
  • Phone: 212-795-1221
  • Fax:
Mailing address:
  • Phone: 212-795-1221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code246Q00000X
TaxonomyPathology Specialist/Technologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code246W00000X
TaxonomyCardiology Technician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2471B0102X
TaxonomyBone Densitometry Radiologic Technologist
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State
# 10
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name: DR. JORGE PINA
Title or Position: PRESIDENT
Credential:
Phone: 646-533-7790