Healthcare Provider Details

I. General information

NPI: 1568223923
Provider Name (Legal Business Name): EASTERN SUFFOLK SPINE AND PAIN MEDICINE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 BOISSEAU AVE
SOUTHOLD NY
11971-2926
US

IV. Provider business mailing address

3 FRANCES LN
PORT JEFFERSON NY
11777-1125
US

V. Phone/Fax

Practice location:
  • Phone: 631-477-5353
  • Fax: 631-477-5891
Mailing address:
  • Phone: 570-814-4146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. NITIN MARIWALLA
Title or Position: CEO
Credential: MD
Phone: 631-885-2406