Basic Information
| Provider Information | |||||||||
| NPI: | 1821580747 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GARDEN STATE SPORTS & PAIN MEDICINE, LLC | ||||||||
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| OtherOrganizationName: | PREMIER PAIN AND SPINE SOLUTIONS, LLC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 480 BEDFORD RD STE 4202 | ||||||||
| Address2: | |||||||||
| City: | CHAPPAQUA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105141716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146668866 | ||||||||
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| Practice Location | |||||||||
| Address1: | 721 CLIFTON AVE STE 2D | ||||||||
| Address2: | |||||||||
| City: | CLIFTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070131880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146668866 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2018 | ||||||||
| LastUpdateDate: | 11/02/2020 | ||||||||
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| AuthorizedOfficialLastName: | KOPPEL | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9146668866 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 11/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No ID Information.