Provider Demographics
NPI:1104211648
Name:REHAB DIAGNOSTICS AND PAIN MEDICINE CENTER, LLC
Entity Type:Organization
Organization Name:REHAB DIAGNOSTICS AND PAIN MEDICINE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:YASSER
Authorized Official - Middle Name:
Authorized Official - Last Name:GOUDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-428-6454
Mailing Address - Street 1:2121 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-1054
Mailing Address - Country:US
Mailing Address - Phone:267-428-6454
Mailing Address - Fax:267-428-6457
Practice Address - Street 1:2121 N BROAD ST
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-1054
Practice Address - Country:US
Practice Address - Phone:267-428-6454
Practice Address - Fax:267-428-6457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-01
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD066786L208100000X, 2081P2900X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty