Provider Demographics
NPI:1659918316
Name:NASSAU SPINE INTRAOP MONITORING MEDICAL
Entity Type:Organization
Organization Name:NASSAU SPINE INTRAOP MONITORING MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KANWARPAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:GREWAL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:516-743-9450
Mailing Address - Street 1:30 MERRICK AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-1580
Mailing Address - Country:US
Mailing Address - Phone:516-743-9450
Mailing Address - Fax:
Practice Address - Street 1:900 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-2145
Practice Address - Country:US
Practice Address - Phone:516-743-9450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NASSAU SPINE TEACHNICAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-12-02
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnosticGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03918421Medicaid