Healthcare Provider Details

I. General information

NPI: 1245586684
Provider Name (Legal Business Name): VANGUARD MEDICAL IMAGING P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2012
Last Update Date: 10/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 OLD COUNTRY RD
PLAINVIEW NY
11803-6501
US

IV. Provider business mailing address

8 CORPORATE CENTER DRIVE 105
MELVILLE NY
11747-3193
US

V. Phone/Fax

Practice location:
  • Phone: 516-495-5200
  • Fax: 516-495-5201
Mailing address:
  • Phone: 631-396-1050
  • Fax: 631-396-0787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number222791-1
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. LISA A CORRENTE
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 516-495-5200