=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306875067
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAUL BENJAMIN ROLEN M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2006
-----------------------------------------------------
Last Update Date | 08/31/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2166 BROADWAY APT 21A
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10024-6673
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-396-2260
-----------------------------------------------------
Fax | 954-698-6963
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2166 BROADWAY APT 21A
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10024-6673
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-396-2260
-----------------------------------------------------
Fax | 954-698-6963
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085D0003X
-----------------------------------------------------
Taxonomy Name | Diagnostic Neuroimaging (Radiology) Physician
-----------------------------------------------------
License Number | 186121
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------