1124102603 NPI number — ADVANCED SPINE CARE AND PAIN MANAGEMENT OF NEW YORK PC

Table of content: (NPI 1124102603)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124102603 NPI number — ADVANCED SPINE CARE AND PAIN MANAGEMENT OF NEW YORK PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED SPINE CARE AND PAIN MANAGEMENT OF NEW YORK PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124102603
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
565 JEWETT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STATEN ISLAND
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10302-2654
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-701-6010
Provider Business Mailing Address Fax Number:
718-447-7831

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
565 JEWETT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATEN ISLAND
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10302-2654
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-701-6010
Provider Business Practice Location Address Fax Number:
718-447-7831
Provider Enumeration Date:
10/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PATHARE
Authorized Official First Name:
SHAILESH
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
718-818-4892

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02006962 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 355618300 . This is a "US DEPT OF LABOR" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0012J1 . This is a "EMPIRE BC BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 205677 . This is a "HIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 4C4399 . This is a "PHS/HEALTHNET" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 8799893 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 173446 . This is a "ELDERPLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: DA0552 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P1883750 . This is a "OXFORD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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