Healthcare Provider Details

I. General information

NPI: 1104973452
Provider Name (Legal Business Name): WEST SIDE RADIOLOGY ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 12/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 10TH AVE DEPT OF RADIOLOGY
NEW YORK NY
10019-1147
US

IV. Provider business mailing address

PO BOX 10268
UNIONDALE NY
11555-0268
US

V. Phone/Fax

Practice location:
  • Phone: 212-590-2930
  • Fax:
Mailing address:
  • Phone: 201-830-3122
  • Fax: 201-200-0838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2085R0205X
TaxonomyRadiological Physics Physician
License Number
License Number State

VIII. Authorized Official

Name: JAY LEE
Title or Position: PRESIDENT
Credential: MD
Phone: 201-830-3122