Provider Demographics
NPI:1043626435
Name:SPINE SPORTS & INTERVENTIONAL PAIN MEDICINE PC
Entity type:Organization
Organization Name:SPINE SPORTS & INTERVENTIONAL PAIN MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANJEEV
Authorized Official - Middle Name:
Authorized Official - Last Name:AGARWAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-486-9100
Mailing Address - Street 1:495 CENTRAL PARK AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:SCARSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10583-1068
Mailing Address - Country:US
Mailing Address - Phone:914-713-8774
Mailing Address - Fax:
Practice Address - Street 1:186 MONTAGUE ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-3634
Practice Address - Country:US
Practice Address - Phone:718-358-1700
Practice Address - Fax:718-489-4101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-07
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208100000X
NY2439891305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No305S00000XManaged Care OrganizationsPoint of ServiceGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02899925Medicaid
NY2A1211Medicare PIN