Provider Demographics
NPI:1558675645
Name:PAIN MANAGEMENT MEDICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:PAIN MANAGEMENT MEDICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RAVI
Authorized Official - Middle Name:K
Authorized Official - Last Name:VENKATARAMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-779-7361
Mailing Address - Street 1:PO BOX 1258
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07012-0758
Mailing Address - Country:US
Mailing Address - Phone:973-779-7361
Mailing Address - Fax:973-779-7385
Practice Address - Street 1:1060 CLIFTON AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-3638
Practice Address - Country:US
Practice Address - Phone:973-779-7361
Practice Address - Fax:973-779-7385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-30
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06850700208VP0014X
NY2065821208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7787522OtherSTATE OF NY
NY2065821OtherLICENSE
NJ25MA06850700OtherLICENSE