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General NPI Number Information
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NPI Number | 1003097270
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Entity Type | Organization
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Legal Business Name | EAST QUEENS MEDICAL DIAGNOSTIC SERVICES, PC
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Dates
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Enumeration Date | 11/16/2007
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Last Update Date | 11/16/2007
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Provider Practice Location Address
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Address Line | 23011 LINDEN BLVD
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City | CAMBRIA HEIGHTS
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State | NY
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Zip | 11411-1851
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Country | US
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Telephone | 718-276-3400
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Fax | 718-276-3402
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Provider Business Mailing Address
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Address Line | 230-11 LINDEN BLVD
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City | CAMBRIA HEIGHTS
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State | NY
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Zip | 11411-1851
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Country | US
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Telephone | 718-276-3400
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Fax | 718-276-3402
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CLINTON J SEWELL
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Credential | M.D.
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Telephone | 718-276-3400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085B0100X
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Taxonomy Name | Body Imaging Physician
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License Number | 116260
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 179357
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License Number State | NY
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