Provider Demographics
NPI:1992968937
Name:STATE NEURODIAGNOSTICS AND PAIN MANAGMENT LLC
Entity type:Organization
Organization Name:STATE NEURODIAGNOSTICS AND PAIN MANAGMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:FASS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:267-265-6750
Mailing Address - Street 1:111 COLFAX RD
Mailing Address - Street 2:
Mailing Address - City:SKILLMAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08558
Mailing Address - Country:US
Mailing Address - Phone:267-265-6750
Mailing Address - Fax:609-466-5494
Practice Address - Street 1:6650 BROWNING RD
Practice Address - Street 2:SUITE U12
Practice Address - City:PENNSAUKEN
Practice Address - State:NJ
Practice Address - Zip Code:08109-1479
Practice Address - Country:US
Practice Address - Phone:856-910-1990
Practice Address - Fax:609-587-2277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-09
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJB42154Medicare UPIN