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General NPI Number Information
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NPI Number | 1538372297
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Entity Type | Organization
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Legal Business Name | INTERVENTIONAL & MULTI-DISCIPLINARY PAIN MANAGEMENT
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Dates
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Enumeration Date | 05/08/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2500 NESCONSET HWY BLDG 24C
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City | STONY BROOK
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State | NY
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Zip | 11790-2555
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Country | US
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Telephone | 631-444-0910
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Fax | 631-689-3814
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Provider Business Mailing Address
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Address Line | PO BOX 1523
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City | STONY BROOK
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State | NY
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Zip | 11790-0907
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Country | US
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Telephone | 631-444-0910
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Fax | 631-689-3814
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. LAURINE ANN ERMISH
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Credential | RN
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Telephone | 631-941-0187
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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