Basic Information
| Provider Information | |||||||||
| NPI: | 1477548360 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAIN TREATMENT MEDICINE OF THE FINGER LAKES PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2005 | ||||||||
| Address2: | |||||||||
| City: | EAST SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130574505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154490513 | ||||||||
| FaxNumber: | 3154452936 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 HAGEN DR | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146252658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5858993450 | ||||||||
| FaxNumber: | 5858993454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2005 | ||||||||
| LastUpdateDate: | 01/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | HOLDER | ||||||||
| AuthorizedOfficialFirstName: | DONOVAN | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5858993450 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02618835 | 05 | NY | MEDICAID | DC0842 | 01 | RRMCR | OTHER |