Provider Demographics
NPI:1114007242
Name:INNOVATIVE PAIN CARE CENTER PC
Entity Type:Organization
Organization Name:INNOVATIVE PAIN CARE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ASMA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDDIQUI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-636-7888
Mailing Address - Street 1:415 AVENEL ST
Mailing Address - Street 2:
Mailing Address - City:AVENEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07001-1147
Mailing Address - Country:US
Mailing Address - Phone:732-636-7888
Mailing Address - Fax:732-636-7887
Practice Address - Street 1:415 AVENEL ST
Practice Address - Street 2:
Practice Address - City:AVENEL
Practice Address - State:NJ
Practice Address - Zip Code:07001-1147
Practice Address - Country:US
Practice Address - Phone:732-636-7888
Practice Address - Fax:732-636-7887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJH72051Medicare UPIN