Provider Demographics
NPI:1295005122
Name:DESIO PAIN INSTITUTE P.A.
Entity Type:Organization
Organization Name:DESIO PAIN INSTITUTE P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:JOANN
Authorized Official - Middle Name:
Authorized Official - Last Name:TIEDEMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-257-5454
Mailing Address - Street 1:PO BOX 1110
Mailing Address - Street 2:
Mailing Address - City:WALL
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-1110
Mailing Address - Country:US
Mailing Address - Phone:732-349-1053
Mailing Address - Fax:732-349-9092
Practice Address - Street 1:452 LAKEHURST RD
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-6344
Practice Address - Country:US
Practice Address - Phone:732-349-1053
Practice Address - Fax:732-349-9092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-10
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06205300208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJF93311Medicare UPIN