=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962614065
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CNY PAIN MANAGEMENT MEDICAL SUITE, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 59 SOUTH FIRST STREET
-----------------------------------------------------
City | FULTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13069
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-593-7715
-----------------------------------------------------
Fax | 315-593-1495
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 59 SOUTH FIRST STREET
-----------------------------------------------------
City | FULTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13069
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-593-7715
-----------------------------------------------------
Fax | 315-593-1495
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MAHESH REDDY KUTHURU
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 315-593-7715
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 215662
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------