Healthcare Provider Details

I. General information

NPI: 1083260806
Provider Name (Legal Business Name): INTEGRATED MUSCULOSKELETAL & SPINE GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2019
Last Update Date: 02/22/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73 GUY LOMBARDO AVE
FREEPORT NY
11520-3714
US

IV. Provider business mailing address

73 GUY LOMBARDO AVE
FREEPORT NY
11520-3714
US

V. Phone/Fax

Practice location:
  • Phone: 516-377-3332
  • Fax: 516-377-3844
Mailing address:
  • Phone: 516-377-3332
  • Fax: 516-377-3844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: JUAN LEDON
Title or Position: PRESIDENT
Credential: MD
Phone: 516-377-3332