Provider Demographics
NPI:1376846774
Name:PROFESSIONAL HEALTH RADIOLOGY P.C
Entity Type:Organization
Organization Name:PROFESSIONAL HEALTH RADIOLOGY P.C
Other - Org Name:PROFESSIONAL HEALTH RADIOLOGY P.C
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEWART
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-755-1010
Mailing Address - Street 1:9828 QUEENS BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4257
Mailing Address - Country:US
Mailing Address - Phone:718-755-1010
Mailing Address - Fax:718-360-2279
Practice Address - Street 1:9828 QUEENS BLVD STE 6
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4257
Practice Address - Country:US
Practice Address - Phone:718-755-1010
Practice Address - Fax:718-360-2279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-07
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200451174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG100043470Medicare PIN
NY503U61Medicare PIN