=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932478443
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEUROSTAR IOM MEDICAL PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2011
-----------------------------------------------------
Last Update Date | 12/29/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9 E 68TH ST STE 1C
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10065-4915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-288-8832
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9 E 68TH ST STE 1C
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10065-4915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ELENA FRID
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 212-288-8832
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number | 249043-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 246Z00000X
-----------------------------------------------------
Taxonomy Name | Other Specialist/Technologist
-----------------------------------------------------
License Number | 249043-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------