Healthcare Provider Details

I. General information

NPI: 1467172676
Provider Name (Legal Business Name): STAND-UP MRI OF EAST ELMHURST, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 09/23/2022
Certification Date: 09/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 MORRIS AVENUE 1ST FLOOR
BRONX NY
10451
US

IV. Provider business mailing address

110 MARCUS DRIVE
MELVILLE NY
11747-4227
US

V. Phone/Fax

Practice location:
  • Phone: 718-540-6898
  • Fax: 718-540-6899
Mailing address:
  • Phone: 631-390-1793
  • Fax: 631-390-1780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: HAROLD M TICE
Title or Position: OWNER
Credential: M.D.
Phone: 631-694-2929