Healthcare Provider Details

I. General information

NPI: 1366692527
Provider Name (Legal Business Name): ATLANTIC ANESTHESIA /PAIN MANAGEMENT MEDICAL SERVICES P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2008
Last Update Date: 08/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 FORT WASHINGTON AVE SUITE 1H
NEW YORK NY
10033-3507
US

IV. Provider business mailing address

436 FORT WASHINGTON AVE SUITE 1H
NEW YORK NY
10033-3507
US

V. Phone/Fax

Practice location:
  • Phone: 212-781-4720
  • Fax: 212-923-9585
Mailing address:
  • Phone: 212-781-4720
  • Fax: 212-923-9585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number214351
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number214351
License Number State

VIII. Authorized Official

Name: DR. DMITRY MIRONOV
Title or Position: PRESIDENT
Credential: MD
Phone: 212-781-4720