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General NPI Number Information
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NPI Number | 1093949893
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Entity Type | Organization
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Legal Business Name | SUPREME MEDICAL DIAGNOSTIC,P.C.
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Dates
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Enumeration Date | 05/07/2009
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Last Update Date | 05/09/2009
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Provider Practice Location Address
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Address Line | 215 E 68TH ST SUITE 8
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City | NEW YORK
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State | NY
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Zip | 10065-5718
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Country | US
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Telephone | 212-288-2553
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Fax |
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Provider Business Mailing Address
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Address Line | 215 E 68TH ST SUITE 8
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City | NEW YORK
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State | NY
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Zip | 10065-5718
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Country | US
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Telephone | 212-288-2553
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. ILYA Y BURSHTEYN
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Credential | M.D.,
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Telephone | 212-288-3474
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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