Provider Demographics
NPI:1831475896
Name:EASTERN PAIN MEDICINE PC
Entity Type:Organization
Organization Name:EASTERN PAIN MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VIMALA
Authorized Official - Middle Name:
Authorized Official - Last Name:UPADHYAYULA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-471-0014
Mailing Address - Street 1:1003 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FISHKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12524-1786
Mailing Address - Country:US
Mailing Address - Phone:845-471-0013
Mailing Address - Fax:845-613-2493
Practice Address - Street 1:1003 MAIN ST
Practice Address - Street 2:
Practice Address - City:FISHKILL
Practice Address - State:NY
Practice Address - Zip Code:12524-1786
Practice Address - Country:US
Practice Address - Phone:845-471-0013
Practice Address - Fax:845-613-2493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-21
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225874207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03482024Medicaid