Healthcare Provider Details

I. General information

NPI: 1619372257
Provider Name (Legal Business Name): NUWAVE MEDICAL PLLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2014
Last Update Date: 10/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1056 W JERICHO TPKE
SMITHTOWN NY
11787-3212
US

IV. Provider business mailing address

1056 W. JERICHO TPKE
SMITHTOWN NY
11787
US

V. Phone/Fax

Practice location:
  • Phone: 631-343-7144
  • Fax: 631-486-9102
Mailing address:
  • Phone: 631-343-7144
  • Fax: 631-486-9102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: NATALIE MARTINO
Title or Position: OFFICE MANAGER
Credential:
Phone: 631-343-7144