Provider Demographics
NPI:1356580039
Name:BAYSIDE PAIN & REHABILITATION MEDICINE, P.C.
Entity type:Organization
Organization Name:BAYSIDE PAIN & REHABILITATION MEDICINE, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KI
Authorized Official - Middle Name:YOUNG
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-463-1133
Mailing Address - Street 1:142-29 37 AVE.
Mailing Address - Street 2:(BASEMENT)
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354
Mailing Address - Country:US
Mailing Address - Phone:718-463-1133
Mailing Address - Fax:718-463-6392
Practice Address - Street 1:142-29 37 AVE.
Practice Address - Street 2:(BASEMENT)
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354
Practice Address - Country:US
Practice Address - Phone:718-463-1133
Practice Address - Fax:718-463-6392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-19
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2009782084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP-904065OtherOXFORD
E-05577Medicare UPIN