Provider Demographics
NPI:1477968014
Name:ADVANCED SPINE AND PAIN OF PA, LLC
Entity type:Organization
Organization Name:ADVANCED SPINE AND PAIN OF PA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:YOUNG
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:888-985-2727
Mailing Address - Street 1:1030 KINGS HWY N
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-1907
Mailing Address - Country:US
Mailing Address - Phone:888-985-2727
Mailing Address - Fax:856-779-0211
Practice Address - Street 1:2000 GRANT AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-4378
Practice Address - Country:US
Practice Address - Phone:888-985-2727
Practice Address - Fax:856-779-0211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-23
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08184600207LP2900X
PAMD066819L2084N0400X
PAMD427900207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA365409Medicare PIN