Provider Demographics
NPI:1073925905
Name:INTERGRATED PAIN DIAGNOSTICS AND REHABILITATION SPECIALISTS
Entity Type:Organization
Organization Name:INTERGRATED PAIN DIAGNOSTICS AND REHABILITATION SPECIALISTS
Other - Org Name:JACKSON HEIGHTS MEDICAL CARE PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:NICOLEAU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-565-2949
Mailing Address - Street 1:7535 31ST AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:EAST ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11370-1857
Mailing Address - Country:US
Mailing Address - Phone:718-565-2949
Mailing Address - Fax:
Practice Address - Street 1:7535 31ST AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:EAST ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11370-1857
Practice Address - Country:US
Practice Address - Phone:718-565-2949
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACKSON HEIGHTS MEDICAL CARE PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-27
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Single Specialty