# EMPIRE STATE PAIN & NEURO ,P.C.

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1558634477
- **Authorized official:** DR. SAMUEL MICHAEL THEAGENE M.D. (PRESIDENT)
- **Authorized official phone:** (631) 654-1120

## Contact information

- **Practice address:** 659 SUFFOLK AVE, BRENTWOOD, NY 11717-4413
- **Practice address phone:** (631) 654-1120
- **Practice address fax:** (631) 654-1681
- **Mailing address:** 659 SUFFOLK AVE, BRENTWOOD, NY 11717-4413
- **Mailing address phone:** (631) 654-1120
- **Mailing address fax:** (631) 654-1681

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208100000X | Physical Medicine & Rehabilitation Physician | 914218 | NY | Yes |

## Other

- **Enumeration date:** 02/23/2012
- **Last updated:** 03/20/2012