Provider Demographics
NPI:1477017929
Name:MOUNTAINSIDE PAIN MANAGEMENT PC
Entity Type:Organization
Organization Name:MOUNTAINSIDE PAIN MANAGEMENT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WALTON
Authorized Official - Last Name:SECOY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-226-1230
Mailing Address - Street 1:185 FAIRFIELD AVE STE 2A
Mailing Address - Street 2:
Mailing Address - City:WEST CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-6417
Mailing Address - Country:US
Mailing Address - Phone:973-226-1230
Mailing Address - Fax:973-226-1232
Practice Address - Street 1:185 FAIRFIELD AVE STE 2A
Practice Address - Street 2:
Practice Address - City:WEST CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006-6417
Practice Address - Country:US
Practice Address - Phone:973-226-1230
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-29
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ725433OtherPTAN