1265488902 NPI number — GARDEN STATE PAIN MANAGEMENT, PA

Table of content: (NPI 1265488902)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265488902 NPI number — GARDEN STATE PAIN MANAGEMENT, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARDEN STATE PAIN MANAGEMENT, 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:
1265488902
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1033 CLIFTON AVE STE 209
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLIFTON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07013-3525
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-473-5752
Provider Business Mailing Address Fax Number:
973-473-2459

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1033 CLIFTON AVE STE 209
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLIFTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07013-3525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-473-5752
Provider Business Practice Location Address Fax Number:
973-473-2459
Provider Enumeration Date:
05/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KOPPEL
Authorized Official First Name:
TODD
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
973-473-5752

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP3300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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