MEDICARE: MEDICAL PAIN MANAGEMENT SERVICES, PLLC

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	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician	237045-1	NY
2	208VP0000X	Pain Medicine Physician		NY
3	208VP0014X	Interventional Pain Medicine Physician		NY
4	363A00000X	Physician Assistant		NY
5	363LA2200X	Adult Health Nurse Practitioner
6	207LP2900X	Pain Medicine (Anesthesiology) Physician	191595	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5508704	OTHER	NY	GHI PPO GROUP #
2	4868	OTHER	NY	CDPHP

General Provider Information

NPI Number	:	1215981261
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICAL PAIN MANAGEMENT SERVICES, PLLC

Provider Business Mailing Address
First Line	:	116 EVERETT RD
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12205-1427
Country	:	US
Telephone Number	:	518-463-0171
Fax Number	:	514-463-0174

Provider Business Practice Location Address
First Line	:	116 EVERETT RD
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12205-1427
Country	:	US
Telephone Number	:	518-463-0171
Fax Number	:	514-463-0174

Authorized Official
Title or Position	:	BILLING SUPERVISOR
Name	:	MELISSA HARRIS
Credential	:
Telephone Number	:	518-463-0171

Provider Enumeration Date	:	05/22/2006
Last Update Date	:	10/10/2024

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