MEDICARE: MAIN STREET RADIOLOGY AT BAYSIDE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780771634
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAIN STREET RADIOLOGY AT BAYSIDE LLC

Provider Business Mailing Address
First Line	:	3211 FRANCIS LEWIS BLVD
Second Line	:
City	:	FLUSHING
State	:	NY
Zip	:	11358-1922
Country	:	US
Telephone Number	:	718-352-9850
Fax Number	:	718-352-0102

Provider Business Practice Location Address
First Line	:	3225 FRANCIS LEWIS BLVD
Second Line	:
City	:	FLUSHING
State	:	NY
Zip	:	11358-1922
Country	:	US
Telephone Number	:	718-428-1500
Fax Number	:	718-428-2475

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. ARI JONISCH
Credential	:	M.D.
Telephone Number	:	718-428-1500

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	11/03/2022

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