Provider Demographics
NPI:1124077938
Name:ADVANCED M.R.I., PC-RAYTEL MEDICAL IMAGING-QUEENS
Entity type:Organization
Organization Name:ADVANCED M.R.I., PC-RAYTEL MEDICAL IMAGING-QUEENS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:M
Authorized Official - Last Name:FLANEGIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-831-1112
Mailing Address - Street 1:7 WATERSIDE XING
Mailing Address - Street 2:3RD FLOOR ATTN: KAREN FRISK, CONTRACTING
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-1540
Mailing Address - Country:US
Mailing Address - Phone:800-367-1095
Mailing Address - Fax:860-298-6127
Practice Address - Street 1:6860 AUSTIN ST
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4220
Practice Address - Country:US
Practice Address - Phone:718-575-0500
Practice Address - Fax:718-275-1258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYH98008160678261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02759Medicare PIN