Healthcare Provider Details

I. General information

NPI: 1497987499
Provider Name (Legal Business Name): VALLEYSTREAM RADIOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2009
Last Update Date: 08/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 W MERRICK RD
VALLEY STREAM NY
11580-5532
US

IV. Provider business mailing address

PO BOX 520391
FLUSHING NY
11352-0391
US

V. Phone/Fax

Practice location:
  • Phone: 516-561-5570
  • Fax:
Mailing address:
  • Phone: 516-561-5570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number120848
License Number StateNY

VIII. Authorized Official

Name: MICHAEL GREEN
Title or Position: MD
Credential: M.D.
Phone: 516-561-5570