Basic Information
| Provider Information | |||||||||
| NPI: | 1912075201 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED SPINE AND PAIN, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RELIEVUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1030 NORTH KINGS HIGHWAY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080341907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889852727 | ||||||||
| FaxNumber: | 8567790211 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 EGG HARBOR RD | ||||||||
| Address2: | |||||||||
| City: | SEWELL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080801854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565895340 | ||||||||
| FaxNumber: | 8565895380 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2006 | ||||||||
| LastUpdateDate: | 10/27/2017 | ||||||||
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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 | 54-2177172 | 01 | NJ | HORIZON CASUALITY | OTHER | 54-2177172 | 01 | NJ | PROCURA | OTHER | 54-2177172 | 01 | NJ | HEALTH NET (TRICARE) | OTHER | 54-2177172 | 01 | NJ | PHCS (MULTIPLAN) | OTHER | 54-2177172 | 01 | NJ | US FAMILY HEALTH PLAN | OTHER | 54-2177172 | 01 | NJ | FOCUS | OTHER | 54-2177172 | 01 | NJ | HORIZON BLUE CROSS BLUE SHIELD | OTHER | 54-2177172 | 01 | NJ | UNITED HEALTHCARE/OXFORD | OTHER | 1455155 | 01 | NJ | AETNA | OTHER | 2814308000 | 01 | NJ | AMERIHEALTH, KHPE, PERSONAL CHOICE | OTHER | 54-2177172 | 01 | NJ | CHN SOLUTIONS | OTHER |