Provider Demographics
NPI:1689123929
Name:INTEGRATIVE PAIN & WELLNESS ASSOCIATES, LLC
Entity Type:Organization
Organization Name:INTEGRATIVE PAIN & WELLNESS ASSOCIATES, LLC
Other - Org Name:PAIN MANAGEMENT ASSOCIATES OF WNY, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROMANTH
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGHMARAE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-650-3000
Mailing Address - Street 1:1360 NORTH FOREST ROAD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-1200
Mailing Address - Country:US
Mailing Address - Phone:716-650-3000
Mailing Address - Fax:716-650-3090
Practice Address - Street 1:1360 NORTH FOREST ROAD
Practice Address - Street 2:SUITE 115
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-1200
Practice Address - Country:US
Practice Address - Phone:716-650-3000
Practice Address - Fax:716-650-3090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-28
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY183330-12084N0400X, 208VP0000X
NY258660-1208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty