MEDICARE: PAIN MANAGEMENT OF STONY BROOK 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	174400000X	Specialist

General Provider Information

NPI Number	:	1720467681
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAIN MANAGEMENT OF STONY BROOK P.C.

Provider Business Mailing Address
First Line	:	2500 NESCONSET HWY BLDG 24C
Second Line	:
City	:	STONY BROOK
State	:	NY
Zip	:	11790-2598
Country	:	US
Telephone Number	:	631-371-1489
Fax Number	:	631-638-5028

Provider Business Practice Location Address
First Line	:	2500 NESCONSET HWY BLDG 24C
Second Line	:
City	:	STONY BROOK
State	:	NY
Zip	:	11790-2598
Country	:	US
Telephone Number	:	631-371-1489
Fax Number	:	631-638-5028

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	VERONICA HATZICHRISTOS
Credential	:
Telephone Number	:	631-371-1489

Provider Enumeration Date	:	05/26/2015
Last Update Date	:	05/26/2015

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