Provider Demographics
NPI:1114061074
Name:PAIN MANAGEMENT & REHABILITATIVE PHYSICAL MEDICINE, PC
Entity Type:Organization
Organization Name:PAIN MANAGEMENT & REHABILITATIVE PHYSICAL MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-621-0336
Mailing Address - Street 1:895 CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-2722
Mailing Address - Country:US
Mailing Address - Phone:718-621-0336
Mailing Address - Fax:718-621-0339
Practice Address - Street 1:2281 82ND ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-2603
Practice Address - Country:US
Practice Address - Phone:718-621-0336
Practice Address - Fax:718-621-0339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY166878208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty