Provider Demographics
NPI:1477548360
Name:PAIN TREATMENT MEDICINE OF THE FINGER LAKES PLLC
Entity Type:Organization
Organization Name:PAIN TREATMENT MEDICINE OF THE FINGER LAKES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONOVAN
Authorized Official - Middle Name:O
Authorized Official - Last Name:HOLDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-899-3450
Mailing Address - Street 1:PO BOX 2005
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-4505
Mailing Address - Country:US
Mailing Address - Phone:315-449-0513
Mailing Address - Fax:315-445-2936
Practice Address - Street 1:30 HAGEN DR
Practice Address - Street 2:SUITE 230
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14625-2658
Practice Address - Country:US
Practice Address - Phone:585-899-3450
Practice Address - Fax:585-899-3454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-16
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02618835Medicaid
DC0842OtherRRMCR
BA0167Medicare ID - Type Unspecified
NY02618835Medicaid