Provider Demographics
NPI:1467632182
Name:MEDICAL PAIN MANAGEMENT OF CNY, PC
Entity Type:Organization
Organization Name:MEDICAL PAIN MANAGEMENT OF CNY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:KOWALCZYK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-471-5888
Mailing Address - Street 1:1001 JAMES ST STE 1
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-2707
Mailing Address - Country:US
Mailing Address - Phone:315-471-5888
Mailing Address - Fax:315-471-6336
Practice Address - Street 1:910 ERIE BLVD E
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1060
Practice Address - Country:US
Practice Address - Phone:315-423-4315
Practice Address - Fax:315-471-6336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206367207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01830175Medicaid
NY01830175Medicaid