MEDICARE: TRISTATE NY DIAGNOSTICS INC

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	174400000X	Specialist

General Provider Information

NPI Number	:	1518411412
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRISTATE NY DIAGNOSTICS INC

Provider Business Mailing Address
First Line	:	2464 CONEY ISLAND AVE
Second Line	:	3 FLOOR
City	:	BROOKLYN
State	:	NY
Zip	:	11223-5022
Country	:	US
Telephone Number	:	718-336-2753
Fax Number	:	718-339-0170

Provider Business Practice Location Address
First Line	:	2464 CONEY ISLAND AVE
Second Line	:	3 FLOOR
City	:	BROOKLYN
State	:	NY
Zip	:	11223-5022
Country	:	US
Telephone Number	:	718-336-2753
Fax Number	:	718-339-0170

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RAMAZ MITAISHVILI
Credential	:
Telephone Number	:	718-336-2753

Provider Enumeration Date	:	08/09/2016
Last Update Date	:	08/09/2016

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