Basic Information
| Provider Information | |||||||||
| NPI: | 1942379706 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPINE AND PAIN CENTERS, PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 655 SHREWSBURY AVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | SHREWSBURY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077024179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7323451180 | ||||||||
| FaxNumber: | 7323458029 | ||||||||
| Practice Location | |||||||||
| Address1: | 1430 HOOPER AVE | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | TOMS RIVER | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087532895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7324739530 | ||||||||
| FaxNumber: | 7324739574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 12/11/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BIRD | ||||||||
| AuthorizedOfficialFirstName: | IRENE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 7323451180 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.