Provider Demographics
NPI:1699876706
Name:BISTATE DIAGNOSTIC
Entity type:Organization
Organization Name:BISTATE DIAGNOSTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:REYNALDO
Authorized Official - Middle Name:DUIGUAN
Authorized Official - Last Name:JOSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:276-322-4520
Mailing Address - Street 1:PO BOX 784
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:24605-0784
Mailing Address - Country:US
Mailing Address - Phone:276-322-4520
Mailing Address - Fax:276-322-4520
Practice Address - Street 1:RR2 BOX 26 RIVERBEND EST
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:VA
Practice Address - Zip Code:24605-0784
Practice Address - Country:US
Practice Address - Phone:276-322-4520
Practice Address - Fax:276-322-4520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010342192471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonographyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010269989Medicaid
D49360Medicare UPIN
VAFVCI01Medicare ID - Type Unspecified