Healthcare Provider Details

I. General information

NPI: 1043626435
Provider Name (Legal Business Name): SPINE SPORTS & INTERVENTIONAL PAIN MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2014
Last Update Date: 01/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

186 MONTAGUE ST
BROOKLYN NY
11201-3634
US

IV. Provider business mailing address

495 CENTRAL PARK AVE SUITE 303
SCARSDALE NY
10583-1068
US

V. Phone/Fax

Practice location:
  • Phone: 718-358-1700
  • Fax: 718-489-4101
Mailing address:
  • Phone: 914-713-8774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number2439891
License Number StateNY

VIII. Authorized Official

Name: DR. SANJEEV AGARWAL
Title or Position: OWNER
Credential: MD
Phone: 631-486-9100