=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992752604
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WHITE MOUNTAIN RADIOLOGY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 SAINT JOHNSBURY RD
-----------------------------------------------------
City | LITTLETON
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03561-3442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-444-9577
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17-17 ROUTE 208 WHITE MOUNTAIN ROBERT GAREY CPA PC
-----------------------------------------------------
City | FAIR LAWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07410-2820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-796-6400
-----------------------------------------------------
Fax | 201-796-4110
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | GEORGE BRAFF
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 201-796-6400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number | 11863
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------