MEDICARE: ADVANCED MEDICAL DIAGNOSTICS OF QUEENS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician

General Provider Information

NPI Number	:	1265606750
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED MEDICAL DIAGNOSTICS OF QUEENS PC

Provider Business Mailing Address
First Line	:	6829 SPRINGFIELD BLVD
Second Line	:
City	:	OAKLAND GARDENS
State	:	NY
Zip	:	11364-2632
Country	:	US
Telephone Number	:	718-279-1300
Fax Number	:	718-279-1041

Provider Business Practice Location Address
First Line	:	6829 SPRINGFIELD BLVD
Second Line	:
City	:	OAKLAND GARDENS
State	:	NY
Zip	:	11364-2632
Country	:	US
Telephone Number	:	718-279-1300
Fax Number	:	718-279-1041

Authorized Official
Title or Position	:	OWNER
Name	:	NODARI MIKHELASHVILI
Credential	:	MD
Telephone Number	:	718-279-1300

Provider Enumeration Date	:	04/16/2008
Last Update Date	:	04/16/2008

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