Basic Information
| Provider Information | |||||||||
| NPI: | 1417595224 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REGENERATIVE PAIN CENTER OF NJ & NY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118 N BEDFORD RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | MOUNT KISCO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105492555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146668866 | ||||||||
| FaxNumber: | 9146666777 | ||||||||
| Practice Location | |||||||||
| Address1: | 119 W 57TH ST STE 717 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100192302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9177979523 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2019 | ||||||||
| LastUpdateDate: | 12/12/2019 | ||||||||
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| AuthorizedOfficialLastName: | KOPPEL | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9146668866 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 12/12/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.