Provider Demographics
NPI:1013187582
Name:GARDEN STATE PAIN AND RADIOLOGY CENTER, PC.
Entity Type:Organization
Organization Name:GARDEN STATE PAIN AND RADIOLOGY CENTER, PC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DHARAM
Authorized Official - Middle Name:PAL
Authorized Official - Last Name:MANN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-849-0077
Mailing Address - Street 1:PO BOX 397
Mailing Address - Street 2:
Mailing Address - City:WHITING
Mailing Address - State:NJ
Mailing Address - Zip Code:08759-0397
Mailing Address - Country:US
Mailing Address - Phone:732-849-0077
Mailing Address - Fax:732-849-0015
Practice Address - Street 1:1100 ROUTE 70
Practice Address - Street 2:
Practice Address - City:WHITING
Practice Address - State:NJ
Practice Address - Zip Code:08759-1003
Practice Address - Country:US
Practice Address - Phone:732-849-0077
Practice Address - Fax:732-849-0015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07706000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJH88459Medicare UPIN
NJDE9648Medicare PIN
NJ088474Medicare PIN
NJ5930060001Medicare NSC