Healthcare Provider Details

I. General information

NPI: 1437601325
Provider Name (Legal Business Name): PROSPECT MEDICAL IMAGING P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 10/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

586 MIDLAND AVE STE 2C
STATEN ISLAND NY
10306-5903
US

IV. Provider business mailing address

586 MIDLAND AVE STE 2C
STATEN ISLAND NY
10306-5903
US

V. Phone/Fax

Practice location:
  • Phone: 347-512-1716
  • Fax:
Mailing address:
  • Phone: 347-512-1716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number157428
License Number StateNY

VIII. Authorized Official

Name: MR. DENISE RICHARD
Title or Position: PRESIDENT
Credential: M.D.
Phone: 347-512-1716