=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497023964
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH SHORE TMS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2011
-----------------------------------------------------
Last Update Date | 10/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 75 PROSPECT ST STE 102
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11743-3320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-923-0006
-----------------------------------------------------
Fax | 631-498-0189
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 75 PROSPECT ST STE 105
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11743-3310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-923-0006
-----------------------------------------------------
Fax | 631-498-0189
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | ANDREA R. CARLSEN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 631-923-0006
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 242634
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------