Healthcare Provider Details

I. General information

NPI: 1336260595
Provider Name (Legal Business Name): PAIN AND SPORT MEDICINE OF NEW YORK PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 10/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 E BROADWAY RM 501
NEW YORK NY
10002-6891
US

IV. Provider business mailing address

32 E 76TH ST APT 804
NEW YORK NY
10021-2754
US

V. Phone/Fax

Practice location:
  • Phone: 212-925-8839
  • Fax: 212-226-8498
Mailing address:
  • Phone: 212-925-8839
  • Fax: 212-226-8498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number204326
License Number StateNY

VIII. Authorized Official

Name: MS. JANE YANG
Title or Position: BILLING
Credential:
Phone: 212-925-8839