Healthcare Provider Details

I. General information

NPI: 1295872679
Provider Name (Legal Business Name): NEW YORK SPINE SURGERY & REHABILITATION MEDICINE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 02/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243 NORTH RD SUITE 202S
POUGHKEEPSIE NY
12601-1172
US

IV. Provider business mailing address

243 NORTH RD SUITE 202S
POUGHKEEPSIE NY
12601-1172
US

V. Phone/Fax

Practice location:
  • Phone: 845-471-9200
  • Fax: 845-471-1551
Mailing address:
  • Phone: 845-471-9200
  • Fax: 845-471-1551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number202111-0
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number225259-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number011524-1
License Number StateNY

VIII. Authorized Official

Name: MS. JACQUELINE ELAINE REEDER
Title or Position: OFFICE MANAGER
Credential:
Phone: 845-471-9200