Provider Demographics
NPI:1255498424
Name:UPSTATE PAIN MEDICINE PC
Entity Type:Organization
Organization Name:UPSTATE PAIN MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-529-3950
Mailing Address - Street 1:59 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069-1704
Mailing Address - Country:US
Mailing Address - Phone:315-593-7715
Mailing Address - Fax:315-593-1495
Practice Address - Street 1:59 S 1ST ST
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-1704
Practice Address - Country:US
Practice Address - Phone:315-593-7715
Practice Address - Fax:315-593-1495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215662174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA0527Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER