Provider Demographics
NPI:1104593870
Name:KNOX PAIN MANAGEMENT MEDICAL PRACTICE PLLC
Entity type:Organization
Organization Name:KNOX PAIN MANAGEMENT MEDICAL PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-736-4064
Mailing Address - Street 1:340 ROUTE 202
Mailing Address - Street 2:
Mailing Address - City:SOMERS
Mailing Address - State:NY
Mailing Address - Zip Code:10589-3237
Mailing Address - Country:US
Mailing Address - Phone:845-254-1155
Mailing Address - Fax:631-736-1332
Practice Address - Street 1:340 ROUTE 202
Practice Address - Street 2:
Practice Address - City:SOMERS
Practice Address - State:NY
Practice Address - Zip Code:10589-3237
Practice Address - Country:US
Practice Address - Phone:845-254-1155
Practice Address - Fax:631-736-1332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-30
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05241869Medicaid