Basic Information
| Provider Information | |||||||||
| NPI: | 1477968014 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED SPINE AND PAIN OF PA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1030 KINGS HWY N | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080341907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889852727 | ||||||||
| FaxNumber: | 8567790211 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 GRANT AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191154378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889852727 | ||||||||
| FaxNumber: | 8567790211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2014 | ||||||||
| LastUpdateDate: | 02/06/2015 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | YOUNG | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN, OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8889852727 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 25MA08184600 | NJ | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 2084N0400X | MD066819L | PA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 207LP2900X | MD427900 | PA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.