Basic Information
| Provider Information | |||||||||
| NPI: | 1730359084 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED SPINE AND PAIN LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40109 | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071014001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889852727 | ||||||||
| FaxNumber: | 8567790211 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 8TH ST | ||||||||
| Address2: | |||||||||
| City: | HAMMONTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080373347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889852727 | ||||||||
| FaxNumber: | 8567790211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2008 | ||||||||
| LastUpdateDate: | 09/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | FREAS | ||||||||
| AuthorizedOfficialFirstName: | DAMEAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8889852727 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 09/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 2081P2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 208VP0014X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0154661 | 05 | NJ | MEDICAID |