MEDICARE: ATLANTIC ANESTHESIA /PAIN MANAGEMENT MEDICAL SERVICES P.C.

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	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician	214351
2	207LP2900X	Pain Medicine (Anesthesiology) Physician	214351	NY

General Provider Information

NPI Number	:	1366692527
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATLANTIC ANESTHESIA /PAIN MANAGEMENT MEDICAL SERVICES P.C.

Provider Business Mailing Address
First Line	:	436 FORT WASHINGTON AVE
Second Line	:	SUITE 1H
City	:	NEW YORK
State	:	NY
Zip	:	10033-3507
Country	:	US
Telephone Number	:	212-781-4720
Fax Number	:	212-923-9585

Provider Business Practice Location Address
First Line	:	436 FORT WASHINGTON AVE
Second Line	:	SUITE 1H
City	:	NEW YORK
State	:	NY
Zip	:	10033-3507
Country	:	US
Telephone Number	:	212-781-4720
Fax Number	:	212-923-9585

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DMITRY MIRONOV
Credential	:	MD
Telephone Number	:	212-781-4720

Provider Enumeration Date	:	09/24/2008
Last Update Date	:	08/04/2009

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