1710395991 NPI number — MAIN STREET RADIOLOGY AT BAYSIDE LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710395991 NPI number — MAIN STREET RADIOLOGY AT BAYSIDE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAIN STREET RADIOLOGY AT BAYSIDE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710395991
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3211 FRANCIS LEWIS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLUSHING
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11358-1922
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-352-9850
Provider Business Mailing Address Fax Number:
718-352-0102

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7206 NORTHERN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON HEIGHTS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11372
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-428-1500
Provider Business Practice Location Address Fax Number:
718-428-2475
Provider Enumeration Date:
07/31/2014

Additional Information

Authorized Official

Authorized Official Last Name:
JONISCH
Authorized Official First Name:
ARI
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICER
Authorized Official Telephone Number:
718-428-1500

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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