Basic Information
| Provider Information | |||||||||
| NPI: | 1801340385 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INNOVATIVE SPINE AND PAIN CENTER, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 MARCIN WAY | ||||||||
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| City: | FLANDERS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 078369671 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 90 BERGEN ST | ||||||||
| Address2: | SUITE 3400 | ||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071032425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739722085 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2016 | ||||||||
| LastUpdateDate: | 08/12/2016 | ||||||||
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| AuthorizedOfficialLastName: | LE | ||||||||
| AuthorizedOfficialFirstName: | VANNY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6099156865 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | 25MA08859900 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.