Healthcare Provider Details

I. General information

NPI: 1912037102
Provider Name (Legal Business Name): UNION SQUARE MEDICAL IMAGING AND MAMMOGRAPHY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 10/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PARK AVE S SUITE 1103
NEW YORK NY
10003-1503
US

IV. Provider business mailing address

200 PARK AVE S SUITE 1103
NEW YORK NY
10003-1503
US

V. Phone/Fax

Practice location:
  • Phone: 212-674-0444
  • Fax: 212-477-4163
Mailing address:
  • Phone: 212-674-0444
  • Fax: 212-477-4163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number200740-1
License Number StateNY

VIII. Authorized Official

Name: DR. TERRANCE LEE
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 212-674-0444