Basic Information
Provider Information | |||||||||
NPI: | 1376846774 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PROFESSIONAL HEALTH RADIOLOGY P.C | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PROFESSIONAL HEALTH RADIOLOGY P.C | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9828 QUEENS BLVD STE 6 | ||||||||
Address2: |   | ||||||||
City: | REGO PARK | ||||||||
State: | NY | ||||||||
PostalCode: | 113744257 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7187551010 | ||||||||
FaxNumber: | 7183602279 | ||||||||
Practice Location | |||||||||
Address1: | 9828 QUEENS BLVD STE 6 | ||||||||
Address2: |   | ||||||||
City: | REGO PARK | ||||||||
State: | NY | ||||||||
PostalCode: | 113744257 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7187551010 | ||||||||
FaxNumber: | 7183602279 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/07/2010 | ||||||||
LastUpdateDate: | 08/23/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BAKST | ||||||||
AuthorizedOfficialFirstName: | STEWART | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 7187551010 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 200451 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |   |
No ID Information.