1174676811 NPI number — PAIN MANAGEMENT AND REHABILITATION, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174676811 NPI number — PAIN MANAGEMENT AND REHABILITATION, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN MANAGEMENT AND REHABILITATION, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174676811
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
71 HIDDEN VALLEY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19711-7463
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-733-0507
Provider Business Mailing Address Fax Number:
302-733-7648

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
240 BEISER BLVD
Provider Second Line Business Practice Location Address:
SUITE 201B
Provider Business Practice Location Address City Name:
DOVER
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19904-7790
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-734-7246
Provider Business Practice Location Address Fax Number:
302-678-8890
Provider Enumeration Date:
01/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BALU
Authorized Official First Name:
GANESH
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
302-734-7246

Provider Taxonomy Codes

  • Taxonomy code: 2081P2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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