=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144607995
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VITAL MEDICAL DIAGNOSTICS,PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2015
-----------------------------------------------------
Last Update Date | 04/30/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 713 YONKERS AVE
-----------------------------------------------------
City | YONKERS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-375-6600
-----------------------------------------------------
Fax | 914-377-1366
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 713 YONKERS AVE
-----------------------------------------------------
City | YONKERS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10704-2657
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-375-6600
-----------------------------------------------------
Fax | 914-377-1366
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ILYA YAKOV BURSHTEYN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 914-375-6600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------