Basic Information
| Provider Information | |||||||||
| NPI: | 1407002124 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADVANCED SPINE AND PAIN, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RELIEVERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1030 NORTH KINGS HIGHWAY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080341907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567797774 | ||||||||
| FaxNumber: | 8567790211 | ||||||||
| Practice Location | |||||||||
| Address1: | 1030 NORTH KINGS HIGHWAY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080341907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889852727 | ||||||||
| FaxNumber: | 8567790211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2008 | ||||||||
| LastUpdateDate: | 07/08/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | YOUNG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8889852727 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 2084N0400X | NJ | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2081P2900X | NJ | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 208VP0014X | NJ | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0154661 | 05 | NJ | MEDICAID |