Provider Demographics
NPI:1174929012
Name:NEW YORK PAIN AND SPINE MEDICINE LLC
Entity type:Organization
Organization Name:NEW YORK PAIN AND SPINE MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:MEMPHIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-535-5989
Mailing Address - Street 1:PO BOX 305
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13851-0305
Mailing Address - Country:US
Mailing Address - Phone:301-326-5397
Mailing Address - Fax:607-429-0244
Practice Address - Street 1:409 HOOPER RD
Practice Address - Street 2:
Practice Address - City:ENDWELL
Practice Address - State:NY
Practice Address - Zip Code:13760-3661
Practice Address - Country:US
Practice Address - Phone:301-326-5397
Practice Address - Fax:607-429-0244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY247295208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02946078Medicaid
NY05527502OtherECFMG NUMBE
NY02946078Medicaid
NYRB6913Medicare PIN