=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356527436
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOBILERAD, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2008
-----------------------------------------------------
Last Update Date | 06/15/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27 TIMBERLINE CIR # CL
-----------------------------------------------------
City | PORT JEFFERSON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11777-1440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-642-2240
-----------------------------------------------------
Fax | 631-331-9868
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 708
-----------------------------------------------------
City | MOUNT SINAI
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11766-0708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-642-2240
-----------------------------------------------------
Fax | 631-331-9868
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. JAMIE ARTHUR KIRCHER SR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 631-642-2240
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335V00000X
-----------------------------------------------------
Taxonomy Name | Portable X-ray and/or Other Portable Diagnostic Imaging Supplier
-----------------------------------------------------
License Number | 51023476
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0208X
-----------------------------------------------------
Taxonomy Name | Mobile Radiology Clinic/Center
-----------------------------------------------------
License Number | 51023476
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------