Provider Demographics
NPI:1538372297
Name:INTERVENTIONAL & MULTI-DISCIPLINARY PAIN MANAGEMENT
Entity type:Organization
Organization Name:INTERVENTIONAL & MULTI-DISCIPLINARY PAIN MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURINE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ERMISH
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:631-941-0187
Mailing Address - Street 1:PO BOX 1523
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0907
Mailing Address - Country:US
Mailing Address - Phone:631-444-0910
Mailing Address - Fax:631-689-3814
Practice Address - Street 1:2500 NESCONSET HWY
Practice Address - Street 2:BLDG 24C
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2555
Practice Address - Country:US
Practice Address - Phone:631-444-0910
Practice Address - Fax:631-689-3814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY096933OtherBLUE CROSS BLUE SHIELD