Provider Demographics
NPI:1538510466
Name:SPINE AND PAIN MEDICAL PLLC
Entity Type:Organization
Organization Name:SPINE AND PAIN MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAE
Authorized Official - Middle Name:
Authorized Official - Last Name:KANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-681-9089
Mailing Address - Street 1:200 S BROADWAY
Mailing Address - Street 2:SUITE 205
Mailing Address - City:TARRYTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10591-4500
Mailing Address - Country:US
Mailing Address - Phone:917-572-7108
Mailing Address - Fax:
Practice Address - Street 1:83 MONTGOMERY AVE
Practice Address - Street 2:
Practice Address - City:SCARSDALE
Practice Address - State:NY
Practice Address - Zip Code:10583-5104
Practice Address - Country:US
Practice Address - Phone:914-681-9089
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-22
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6143261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical