Healthcare Provider Details

I. General information

NPI: 1154474070
Provider Name (Legal Business Name): HOLISTIC PAIN MEDICINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2333 65TH ST
BROOKLYN NY
11204-4045
US

IV. Provider business mailing address

343 E 51ST ST APT 1D
NEW YORK NY
10022-6756
US

V. Phone/Fax

Practice location:
  • Phone: 718-336-1500
  • Fax:
Mailing address:
  • Phone: 646-244-4405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SERGEY ILIYEV
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 646-244-4405