Provider Demographics
NPI:1679831507
Name:INTERVENTIONAL SPINAL PAIN CARE PC
Entity Type:Organization
Organization Name:INTERVENTIONAL SPINAL PAIN CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:CANTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-524-7246
Mailing Address - Street 1:149 MADISON AVE RM 702
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6713
Mailing Address - Country:US
Mailing Address - Phone:917-524-7246
Mailing Address - Fax:718-509-6961
Practice Address - Street 1:149 MADISON AVE RM 702
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6713
Practice Address - Country:US
Practice Address - Phone:917-524-7246
Practice Address - Fax:718-509-6961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-28
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY237504207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6687260001Medicare NSC