Provider Demographics
NPI:1487968343
Name:MAIN STREET DIAGNOSTIC INC
Entity type:Organization
Organization Name:MAIN STREET DIAGNOSTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NINEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIDOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-210-1000
Mailing Address - Street 1:6854 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-1325
Mailing Address - Country:US
Mailing Address - Phone:646-210-1000
Mailing Address - Fax:
Practice Address - Street 1:6854 MAIN ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-1325
Practice Address - Country:US
Practice Address - Phone:646-210-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-03
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty