Basic Information
| Provider Information | |||||||||
| NPI: | 1538222740 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANTAGE P M & R LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 60 DUNNING RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109402215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453444477 | ||||||||
| FaxNumber: | 8453446072 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 DUNNING RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453444477 | ||||||||
| FaxNumber: | 8453446072 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 11/01/2011 | ||||||||
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| AuthorizedOfficialLastName: | VINCENT | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 8453444477 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 2175981 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081P2900X | 1928462 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 2081P2900X | 2005021 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01575286 | 05 | NY | MEDICAID | 02088562 | 05 | NY | MEDICAID | 02688757 | 05 | NY | MEDICAID |