Provider Demographics
NPI:1992980791
Name:NEUROSURGERY & PAIN REHABILITATION CENTER
Entity type:Organization
Organization Name:NEUROSURGERY & PAIN REHABILITATION CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RODRIGO
Authorized Official - Middle Name:
Authorized Official - Last Name:ESTONILO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-421-8772
Mailing Address - Street 1:100 EAGLESMERE CIR
Mailing Address - Street 2:200A
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-3144
Mailing Address - Country:US
Mailing Address - Phone:570-421-8772
Mailing Address - Fax:570-421-8775
Practice Address - Street 1:100 EAGLESMERE CIR
Practice Address - Street 2:200A
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-3144
Practice Address - Country:US
Practice Address - Phone:570-421-8772
Practice Address - Fax:570-421-8775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-31
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042667L207T00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1020667750001Medicaid
PA1020667750001Medicaid
PA121488Medicare PIN