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General NPI Number Information
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NPI Number | 1275720278
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Entity Type | Organization
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Legal Business Name | SPINE AND PERIPHERAL NEUROCARE, PC
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Dates
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Enumeration Date | 10/03/2007
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Last Update Date | 04/28/2011
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Provider Practice Location Address
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Address Line | 420 E 72ND ST SUITE 1J
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City | NEW YORK
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State | NY
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Zip | 10021-4650
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Country | US
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Telephone | 212-988-4815
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Fax | 212-988-1122
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Provider Business Mailing Address
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Address Line | 420 E 72ND ST SUITE 1J
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City | NEW YORK
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State | NY
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Zip | 10021-4650
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Country | US
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Telephone | 212-988-4815
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Fax | 212-988-1122
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Authorized Official
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Title or Position | MANAGING DIRECTOR
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Name | DR. CARL W. HEISE
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Credential | M.D.
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Telephone | 212-988-4815
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | 185547
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License Number State | NY
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