Provider Demographics
NPI:1295872679
Name:NEW YORK SPINE SURGERY & REHABILITATION MEDICINE, PLLC
Entity type:Organization
Organization Name:NEW YORK SPINE SURGERY & REHABILITATION MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:REEDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-471-9200
Mailing Address - Street 1:243 NORTH RD
Mailing Address - Street 2:SUITE 202S
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-1172
Mailing Address - Country:US
Mailing Address - Phone:845-471-9200
Mailing Address - Fax:845-471-1551
Practice Address - Street 1:243 NORTH RD
Practice Address - Street 2:SUITE 202S
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-1172
Practice Address - Country:US
Practice Address - Phone:845-471-9200
Practice Address - Fax:845-471-1551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225259-1208100000X
NY011524-1363AM0700X
NY202111-0207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR000OtherCDPHP
NYWEV831Medicare ID - Type Unspecified