Healthcare Provider Details

I. General information

NPI: 1902852247
Provider Name (Legal Business Name): EAST END PAIN MANAGEMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 02/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 COUNTY ROAD 39A SUITE 15 & 16
SOUTHAMPTON NY
11968
US

IV. Provider business mailing address

365 COUNTY ROAD 39A SUITE 15 & 16
SOUTHAMPTON NY
11968
US

V. Phone/Fax

Practice location:
  • Phone: 631-702-2300
  • Fax: 631-702-2303
Mailing address:
  • Phone: 631-702-2300
  • Fax: 631-702-2303

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: JUAN J. GARGIULO
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 631-702-2300