Provider Demographics
NPI:1184008658
Name:BAYSIDE PAIN MANAGEMENT PC
Entity Type:Organization
Organization Name:BAYSIDE PAIN MANAGEMENT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ARISTIDE
Authorized Official - Middle Name:
Authorized Official - Last Name:BURDUCEA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:718-220-0439
Mailing Address - Street 1:247 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-5819
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:247 W 16TH ST
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-5819
Practice Address - Country:US
Practice Address - Phone:646-982-7281
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-15
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY243366208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03032322Medicaid
NYA400108448Medicare PIN