Provider Demographics
NPI:1558634477
Name:EMPIRE STATE PAIN & NEURO ,P.C.
Entity Type:Organization
Organization Name:EMPIRE STATE PAIN & NEURO ,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:THEAGENE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-654-1120
Mailing Address - Street 1:659 SUFFOLK AVE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-4413
Mailing Address - Country:US
Mailing Address - Phone:631-654-1120
Mailing Address - Fax:631-654-1681
Practice Address - Street 1:659 SUFFOLK AVE
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4413
Practice Address - Country:US
Practice Address - Phone:631-654-1120
Practice Address - Fax:631-654-1681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-23
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY914218208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty