Healthcare Provider Details

I. General information

NPI: 1932478443
Provider Name (Legal Business Name): NEUROSTAR IOM MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2011
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 E 68TH ST STE 1C
NEW YORK NY
10065-4915
US

IV. Provider business mailing address

9 E 68TH ST STE 1C
NEW YORK NY
10065-4915
US

V. Phone/Fax

Practice location:
  • Phone: 212-288-8832
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number249043-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number249043-1
License Number StateNY

VIII. Authorized Official

Name: DR. ELENA FRID
Title or Position: PRESIDENT
Credential: M.D.
Phone: 212-288-8832