Healthcare Provider Details

I. General information

NPI: 1215981261
Provider Name (Legal Business Name): MEDICAL PAIN MANAGEMENT SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 EVERETT RD
ALBANY NY
12205-1427
US

IV. Provider business mailing address

116 EVERETT RD
ALBANY NY
12205-1427
US

V. Phone/Fax

Practice location:
  • Phone: 518-463-0171
  • Fax: 514-463-0174
Mailing address:
  • Phone: 518-463-0171
  • Fax: 514-463-0174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number237045-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number191595
License Number StateNY

VIII. Authorized Official

Name: MELISSA HARRIS
Title or Position: BILLING SUPERVISOR
Credential:
Phone: 518-463-0171