Provider Demographics
NPI:1437633492
Name:BAYONNE PAIN MANAGEMENT CENTER, LLC
Entity Type:Organization
Organization Name:BAYONNE PAIN MANAGEMENT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAMDOUH
Authorized Official - Middle Name:S
Authorized Official - Last Name:HANNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-303-7700
Mailing Address - Street 1:631 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-3846
Mailing Address - Country:US
Mailing Address - Phone:201-471-7246
Mailing Address - Fax:201-471-7242
Practice Address - Street 1:631 BROADWAY
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-3846
Practice Address - Country:US
Practice Address - Phone:201-471-7246
Practice Address - Fax:201-471-7242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-17
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJAPPLIEDMedicaid