Healthcare Provider Details

I. General information

NPI: 1003381146
Provider Name (Legal Business Name): SPINE AND PAIN CONSULTANT, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2018
Last Update Date: 01/27/2023
Certification Date: 01/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOLLOW LN STE 102
NEW HYDE PARK NY
11042-1219
US

IV. Provider business mailing address

1360 HYLAN BLVD
STATEN ISLAND NY
10305-1922
US

V. Phone/Fax

Practice location:
  • Phone: 516-587-5500
  • Fax:
Mailing address:
  • Phone: 718-667-3577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KENNETH B CHAPMAN
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 718-667-3577