Provider Demographics
NPI:1942397880
Name:MAIN STREET RADIOLOGY AT BAYSIDE LLC
Entity Type:Organization
Organization Name:MAIN STREET RADIOLOGY AT BAYSIDE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:WOLFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-352-9850
Mailing Address - Street 1:3211 FRANCIS LEWIS BLVD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-1922
Mailing Address - Country:US
Mailing Address - Phone:718-352-9850
Mailing Address - Fax:718-352-0102
Practice Address - Street 1:13625 37TH AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-4169
Practice Address - Country:US
Practice Address - Phone:718-428-1500
Practice Address - Fax:718-661-1305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02217256Medicaid
NY02217256Medicaid