1497029599 NPI number — EASTERN REGIONAL PAIN MGT, 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 1497029599 NPI number — EASTERN REGIONAL PAIN MGT, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTERN REGIONAL PAIN MGT, 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:
1497029599
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4979 OLD STREET RD
Provider Second Line Business Mailing Address:
SUITE 1A
Provider Business Mailing Address City Name:
TREVOSE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19053-6222
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-953-8882
Provider Business Mailing Address Fax Number:
215-953-8822

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
151 FRIES MILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TURNERSVILLE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08012-2016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-401-8864
Provider Business Practice Location Address Fax Number:
215-953-8822
Provider Enumeration Date:
03/07/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
COSTELLO
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
215-953-8882

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  OS005840L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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