Provider Demographics
NPI:1508146341
Name:STATEN ISLAND PAIN & REHABILITATION, P.C.
Entity Type:Organization
Organization Name:STATEN ISLAND PAIN & REHABILITATION, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:516-967-6255
Mailing Address - Street 1:4247 RICHMOND AVE
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-6220
Mailing Address - Country:US
Mailing Address - Phone:718-966-7246
Mailing Address - Fax:718-966-7247
Practice Address - Street 1:4247 RICHMOND AVE
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-6220
Practice Address - Country:US
Practice Address - Phone:718-966-7246
Practice Address - Fax:718-966-7247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-24
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYA-243211-1208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty