Provider Demographics
NPI:1366826778
Name:FAIR LAWN PAIN MANAGEMENT LLC
Entity Type:Organization
Organization Name:FAIR LAWN PAIN MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VIJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-777-5444
Mailing Address - Street 1:1117 ROUTE 46
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-2449
Mailing Address - Country:US
Mailing Address - Phone:973-777-5444
Mailing Address - Fax:
Practice Address - Street 1:28-06 BROADWAY
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3913
Practice Address - Country:US
Practice Address - Phone:201-475-8940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-15
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08578900207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty