MEDICARE: UNION SQUARE MEDICAL IMAGING AND MAMMOGRAPHY PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0206X	Mammography Clinic/Center	200740-1	NY

General Provider Information

NPI Number	:	1912037102
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNION SQUARE MEDICAL IMAGING AND MAMMOGRAPHY PC

Provider Business Mailing Address
First Line	:	200 PARK AVE S
Second Line	:	SUITE 1103
City	:	NEW YORK
State	:	NY
Zip	:	10003-1503
Country	:	US
Telephone Number	:	212-674-0444
Fax Number	:	212-477-4163

Provider Business Practice Location Address
First Line	:	200 PARK AVE S
Second Line	:	SUITE 1103
City	:	NEW YORK
State	:	NY
Zip	:	10003-1503
Country	:	US
Telephone Number	:	212-674-0444
Fax Number	:	212-477-4163

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. TERRANCE LEE
Credential	:	MD
Telephone Number	:	212-674-0444

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	10/27/2016

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