Basic Information
| Provider Information | |||||||||
| NPI: | 1730127358 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED SPINE AND PAIN, LLC | ||||||||
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| OtherOrganizationName: | RELIEVUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1030 KINGS HWY N STE 200 | ||||||||
| Address2: | |||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080341907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889852727 | ||||||||
| FaxNumber: | 8567790211 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 E TOWNSHIP LINE RD | ||||||||
| Address2: | FIRST FLOOR | ||||||||
| City: | HAVERTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190835733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4844581000 | ||||||||
| FaxNumber: | 4844581001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 10/25/2017 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | YOUNG | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8889852727 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 207L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 208VP0014X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1010935440001 | 05 | PA | MEDICAID | 1247138 | 01 | PA | AMERICHOICE PPO | OTHER | DA6164 | 01 | PA | RAILROAD MEDICARE GROUP | OTHER | 1426867 | 01 | PA | PERSONAL CHOICE | OTHER | 0091324 | 05 | NJ | MEDICAID | 11-3650843 | 01 | NJ | HORIZON BLUE CROSS BLUE SHIELD OF NJ | OTHER | 1426867 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 2115319000 | 01 | PA | KEYSTONE HEALTH PLAN EAST | OTHER |