=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407018633
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRAMERCY MEDICAL PAIN MANAGEMENT P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2008
-----------------------------------------------------
Last Update Date | 10/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 67 S MAIN ST
-----------------------------------------------------
City | PEARL RIVER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10965-2444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-368-0800
-----------------------------------------------------
Fax | 845-368-0810
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 146
-----------------------------------------------------
City | PEARL RIVER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10965-0146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-368-0800
-----------------------------------------------------
Fax | 845-368-0810
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. SCOTT LAWRENCE GOTTLIEB
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 845-368-0800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 231296-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------