Provider Demographics
NPI:1154427987
Name:QUEENS RADIOLOGY MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:QUEENS RADIOLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:LIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-913-4860
Mailing Address - Street 1:PO BOX 657
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91793-0657
Mailing Address - Country:US
Mailing Address - Phone:909-595-4595
Mailing Address - Fax:909-595-4365
Practice Address - Street 1:1300 N VERMONT AVE
Practice Address - Street 2:DEPARTMENT OF RADIOLOGY
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6005
Practice Address - Country:US
Practice Address - Phone:323-913-4860
Practice Address - Fax:323-913-4922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Single Specialty
Not Answered2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Single Specialty
Not Answered2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Single Specialty
Not Answered2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric RadiologyGroup - Single Specialty
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Not Answered2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Not Answered2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0000080Medicaid
CAGR0000080Medicaid