Basic Information
| Provider Information | |||||||||
| NPI: | 1568571834 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN NEW YORK NEUROSURGICAL GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COMPREHENSIVE PAIN RELIEF | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 200 FRONT ST | ||||||||
| Address2: | |||||||||
| City: | VESTAL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 138501559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077487468 | ||||||||
| FaxNumber: | 6077546130 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 FRONT ST | ||||||||
| Address2: | |||||||||
| City: | VESTAL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 138501559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077487468 | ||||||||
| FaxNumber: | 6077546130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 10/22/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KAMMERMAN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PAIN SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 6077487468 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01376512 | 05 | NY | MEDICAID |