=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780933499
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARDINAL SPINE AND PAIN MEDICINE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2012
-----------------------------------------------------
Last Update Date | 11/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1323 ROUTE 9 SUITE 206
-----------------------------------------------------
City | WAPPINGERS FALLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12590-4904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-297-2225
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 512
-----------------------------------------------------
City | FISHKILL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12524-0512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NIRAJ SHARMA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 215-901-5322
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number | 243413
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------