1205272242 NPI number — NEW JERSEY SPINE AND PAIN, PC

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 1205272242 NPI number — NEW JERSEY SPINE AND PAIN, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW JERSEY SPINE AND PAIN, PC
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:
1205272242
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
725 RIVER RD
Provider Second Line Business Mailing Address:
SUITE 32-107
Provider Business Mailing Address City Name:
EDGEWATER
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07020-1171
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-988-0699
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
725 RIVER RD
Provider Second Line Business Practice Location Address:
SUITE 32-107
Provider Business Practice Location Address City Name:
EDGEWATER
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07020-1171
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-988-0699
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/17/2013

Additional Information

Authorized Official

Authorized Official Last Name:
IZEOGU
Authorized Official First Name:
CHINWEIKE
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
201-988-0699

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X , with the licence number:  25MA08075700 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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