1790711257 NPI number — GLOUCESTER COUNTY PAIN ASSOCIATES PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790711257 NPI number — GLOUCESTER COUNTY PAIN ASSOCIATES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLOUCESTER COUNTY PAIN ASSOCIATES PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790711257
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 390
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCRANTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-346-7797
Provider Business Mailing Address Fax Number:
570-342-9802

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
509 NORTH BROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODBURY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08096
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-845-0100
Provider Business Practice Location Address Fax Number:
856-853-9334
Provider Enumeration Date:
06/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DRASON
Authorized Official First Name:
GLENN
Authorized Official Middle Name:
Authorized Official Title or Position:
HEAD OF GROUP
Authorized Official Telephone Number:
856-845-0100

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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