=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528674611
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A & E MEDICAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2020
-----------------------------------------------------
Last Update Date | 11/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2174 FLATBUSH AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11234-4326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-717-1839
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 HICKSVILLE RD
-----------------------------------------------------
City | BETHPAGE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11714-3443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-717-1839
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | ABRAHAM KNOLL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 516-717-1887
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------