Provider Demographics
NPI:1396929352
Name:EASTSIDE MEDICAL RADIOLOGY PLLC
Entity type:Organization
Organization Name:EASTSIDE MEDICAL RADIOLOGY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-369-9200
Mailing Address - Street 1:170 EAST 77TH STREET
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-1912
Mailing Address - Country:US
Mailing Address - Phone:212-369-9200
Mailing Address - Fax:212-369-5048
Practice Address - Street 1:170 EAST 77TH STREET
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-1912
Practice Address - Country:US
Practice Address - Phone:212-369-9200
Practice Address - Fax:212-369-5048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWJW601Medicare PIN