Provider Demographics
NPI:1265488902
Name:GARDEN STATE PAIN MANAGEMENT, PA
Entity Type:Organization
Organization Name:GARDEN STATE PAIN MANAGEMENT, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:S
Authorized Official - Last Name:KOPPEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-473-5752
Mailing Address - Street 1:1033 CLIFTON AVE STE 209
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-3525
Mailing Address - Country:US
Mailing Address - Phone:973-473-5752
Mailing Address - Fax:973-473-2459
Practice Address - Street 1:1033 CLIFTON AVE STE 209
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-3525
Practice Address - Country:US
Practice Address - Phone:973-473-5752
Practice Address - Fax:973-473-2459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2023-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPainGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ065624Medicare ID - Type Unspecified