Basic Information
| Provider Information | |||||||||
| NPI: | 1508859620 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLSVILLE RADIOLOGY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 GATES RD | ||||||||
| Address2: | STE 3 | ||||||||
| City: | VESTAL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 138502288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077729462 | ||||||||
| FaxNumber: | 6077721223 | ||||||||
| Practice Location | |||||||||
| Address1: | 191 N MAIN ST | ||||||||
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| City: | WELLSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148951150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5855931100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2005 | ||||||||
| LastUpdateDate: | 07/19/2007 | ||||||||
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| AuthorizedOfficialLastName: | AYYUB | ||||||||
| AuthorizedOfficialFirstName: | MOHAMMAD | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5855931100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 134475 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.