MEDICARE: EASTERN SUFFOLK SPINE AND PAIN MEDICINE, PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207L00000X	Anesthesiology Physician
2	207T00000X	Neurological Surgery Physician
3	207RG0100X	Gastroenterology Physician

General Provider Information

NPI Number	:	1568223923
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTERN SUFFOLK SPINE AND PAIN MEDICINE, PLLC

Provider Business Mailing Address
First Line	:	3 FRANCES LN
Second Line	:
City	:	PORT JEFFERSON
State	:	NY
Zip	:	11777-1125
Country	:	US
Telephone Number	:	570-814-4146
Fax Number	:

Provider Business Practice Location Address
First Line	:	700 BOISSEAU AVE
Second Line	:
City	:	SOUTHOLD
State	:	NY
Zip	:	11971-2926
Country	:	US
Telephone Number	:	631-477-5353
Fax Number	:	631-477-5891

Authorized Official
Title or Position	:	CEO
Name	:	DR. NITIN MARIWALLA
Credential	:	MD
Telephone Number	:	631-885-2406

Provider Enumeration Date	:	01/22/2024
Last Update Date	:	07/30/2025

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