Provider Demographics
NPI:1407018633
Name:GRAMERCY MEDICAL PAIN MANAGEMENT P.A.
Entity type:Organization
Organization Name:GRAMERCY MEDICAL PAIN MANAGEMENT P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:GOTTLIEB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-368-0800
Mailing Address - Street 1:PO BOX 146
Mailing Address - Street 2:
Mailing Address - City:PEARL RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:10965-0146
Mailing Address - Country:US
Mailing Address - Phone:845-368-0800
Mailing Address - Fax:845-368-0810
Practice Address - Street 1:67 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PEARL RIVER
Practice Address - State:NY
Practice Address - Zip Code:10965-2444
Practice Address - Country:US
Practice Address - Phone:845-368-0800
Practice Address - Fax:845-368-0810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-29
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231296-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI26388Medicare UPIN