Basic Information
| Provider Information | |||||||||
| NPI: | 1992477590 | ||||||||
| 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 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2800 S 20TH STREET QUARTERMASTER BUILDING | ||||||||
| Address2: | SUITE D | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191451914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889852727 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2021 | ||||||||
| LastUpdateDate: | 10/01/2021 | ||||||||
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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 | ||||||||
| NPICertificationDate: | 09/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
No ID Information.