Provider Demographics
NPI:1235484726
Name:NEW YORK INTERVENTIONAL SPINE AND PAIN MEDICINE PC
Entity Type:Organization
Organization Name:NEW YORK INTERVENTIONAL SPINE AND PAIN MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ABDULQUADER
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:646-732-7139
Mailing Address - Street 1:405 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-3315
Mailing Address - Country:US
Mailing Address - Phone:646-732-7139
Mailing Address - Fax:718-768-7303
Practice Address - Street 1:405 5TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-3315
Practice Address - Country:US
Practice Address - Phone:646-732-7139
Practice Address - Fax:718-768-7303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-20
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251646261QM2500X, 261QP3300X
NY000135363A00000X
NY003681363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPainGroup - Multi-Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03289269Medicaid
NY03289269Medicaid