=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417211681
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALFA IMAGING GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2012
-----------------------------------------------------
Last Update Date | 07/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 SOUTH AVE SUITE 202,#62
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10314-3418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-462-9159
-----------------------------------------------------
Fax | 347-462-9158
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 SOUTH AVE SUITE 202,#62
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10314-3418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-462-9159
-----------------------------------------------------
Fax | 347-462-9158
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | SABINA SERBIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 347-462-9159
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 162663
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------