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General NPI Number Information
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NPI Number | 1568223923
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Entity Type | Organization
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Legal Business Name | EASTERN SUFFOLK SPINE AND PAIN MEDICINE, PLLC
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Dates
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Enumeration Date | 01/22/2024
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Last Update Date | 07/30/2025
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Provider Practice Location Address
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Address Line | 700 BOISSEAU AVE
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City | SOUTHOLD
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State | NY
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Zip | 11971-2926
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Country | US
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Telephone | 631-477-5353
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Fax | 631-477-5891
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Provider Business Mailing Address
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Address Line | 3 FRANCES LN
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City | PORT JEFFERSON
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State | NY
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Zip | 11777-1125
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Country | US
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Telephone | 570-814-4146
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. NITIN MARIWALLA
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Credential | MD
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Telephone | 631-885-2406
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207T00000X
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Taxonomy Name | Neurological Surgery Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number |
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License Number State |
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