Provider Demographics
NPI:1477090777
Name:PROFESSIONAL PAIN MANAGEMENT
Entity Type:Organization
Organization Name:PROFESSIONAL PAIN MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:CORDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-703-5097
Mailing Address - Street 1:2007 N BLACK HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08094-9120
Mailing Address - Country:US
Mailing Address - Phone:856-740-4888
Mailing Address - Fax:
Practice Address - Street 1:2007 N BLACK HORSE PIKE
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08094-9120
Practice Address - Country:US
Practice Address - Phone:856-740-4888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB04459800332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site