Basic Information
| Provider Information | |||||||||
| NPI: | 1538569561 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DR. KEITH RADBILL PAIN MANAGEMENT, LLC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 602 W. MAPLE AVE. | ||||||||
| Address2: | |||||||||
| City: | MERCHANTVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563751500 | ||||||||
| FaxNumber: | 6094828024 | ||||||||
| Practice Location | |||||||||
| Address1: | 602 W. MAPLE AVE. | ||||||||
| Address2: | |||||||||
| City: | MERCHANTVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563751500 | ||||||||
| FaxNumber: | 6094828024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2014 | ||||||||
| LastUpdateDate: | 08/29/2014 | ||||||||
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| AuthorizedOfficialLastName: | RADBILL | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8563751500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25MB07528500 | NJ | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207LP2900X | 25MB07528500 | NJ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.