MEDICARE: ORIGIN PAIN MANAGEMENT AND MEDICAL CARE, 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871771402
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORIGIN PAIN MANAGEMENT AND MEDICAL CARE, PLLC

Provider Business Mailing Address
First Line	:	110 LEAHY ST
Second Line	:
City	:	JERICHO
State	:	NY
Zip	:	11753-1618
Country	:	US
Telephone Number	:	718-462-1100
Fax Number	:	718-462-1900

Provider Business Practice Location Address
First Line	:	486 LINCOLN PL
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11238-6202
Country	:	US
Telephone Number	:	718-462-1100
Fax Number	:	718-462-1900

Authorized Official
Title or Position	:	OWNER
Name	:	DR. GETAHUN KIFLE
Credential	:	MD
Telephone Number	:	718-462-1100

Provider Enumeration Date	:	02/06/2008
Last Update Date	:	07/21/2022

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