=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467172676
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STAND-UP MRI OF EAST ELMHURST, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2022
-----------------------------------------------------
Last Update Date | 09/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 618 MORRIS AVENUE 1ST FLOOR
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-540-6898
-----------------------------------------------------
Fax | 718-540-6899
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 MARCUS DRIVE
-----------------------------------------------------
City | MELVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11747-4227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-390-1793
-----------------------------------------------------
Fax | 631-390-1780
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | HAROLD M TICE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 631-694-2929
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------