Provider Demographics
NPI:1255431144
Name:SPINE & PAIN CARE LLC
Entity type:Organization
Organization Name:SPINE & PAIN CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER LLC
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORTHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-271-1620
Mailing Address - Street 1:PO BOX 18125
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-0125
Mailing Address - Country:US
Mailing Address - Phone:585-271-1620
Mailing Address - Fax:585-271-1634
Practice Address - Street 1:1882 WINTON RD S
Practice Address - Street 2:STE 6
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-3951
Practice Address - Country:US
Practice Address - Phone:585-271-1620
Practice Address - Fax:585-271-1634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2140782081P2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA0210Medicare PIN