MEDICARE: NY PAIN PRACTICE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	204D00000X	Neuromusculoskeletal Medicine & OMM Physician	223679	NY

General Provider Information

NPI Number	:	1083032916
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NY PAIN PRACTICE LLC

Provider Business Mailing Address
First Line	:	4287 KATONAH AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10470-2122
Country	:	US
Telephone Number	:	646-379-8940
Fax Number	:

Provider Business Practice Location Address
First Line	:	4287 KATONAH AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10470-2122
Country	:	US
Telephone Number	:	646-379-8940
Fax Number	:

Authorized Official
Title or Position	:	OFFICER
Name	:	ANGELA STROE
Credential	:	D.O.
Telephone Number	:	914-384-3746

Provider Enumeration Date	:	03/28/2014
Last Update Date	:	10/24/2014

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