Provider Demographics
NPI:1033227004
Name:INSTITUTE FOR DIAGNOSIS & TREATMENT OF PAIN
Entity Type:Organization
Organization Name:INSTITUTE FOR DIAGNOSIS & TREATMENT OF PAIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRAKHINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-796-7666
Mailing Address - Street 1:33-00 BROADWAY
Mailing Address - Street 2:SUITE # 209
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-4617
Mailing Address - Country:US
Mailing Address - Phone:201-796-7666
Mailing Address - Fax:201-796-5570
Practice Address - Street 1:33-00 BROADWAY
Practice Address - Street 2:SUITE # 209
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-4617
Practice Address - Country:US
Practice Address - Phone:201-796-7666
Practice Address - Fax:201-796-5570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA068923174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7979100Medicaid
NJ088012Medicare ID - Type Unspecified
NJ7979100Medicaid