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General NPI Number Information
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NPI Number | 1558634477
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Entity Type | Organization
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Legal Business Name | EMPIRE STATE PAIN & NEURO ,P.C.
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Dates
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Enumeration Date | 02/23/2012
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Last Update Date | 03/20/2012
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Provider Practice Location Address
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Address Line | 659 SUFFOLK AVE
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City | BRENTWOOD
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State | NY
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Zip | 11717-4413
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Country | US
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Telephone | 631-654-1120
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Fax | 631-654-1681
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Provider Business Mailing Address
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Address Line | 659 SUFFOLK AVE
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City | BRENTWOOD
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State | NY
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Zip | 11717-4413
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Country | US
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Telephone | 631-654-1120
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Fax | 631-654-1681
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SAMUEL MICHAEL THEAGENE
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Credential | M.D.
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Telephone | 631-654-1120
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 914218
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License Number State | NY
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