Provider Demographics
NPI:1578505830
Name:ATLANTIC PAIN AND PHYSICAL MEDICINE PC
Entity Type:Organization
Organization Name:ATLANTIC PAIN AND PHYSICAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:M
Authorized Official - Last Name:HAIRSTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-652-3933
Mailing Address - Street 1:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:NJ
Mailing Address - Zip Code:08240-0306
Mailing Address - Country:US
Mailing Address - Phone:609-652-3933
Mailing Address - Fax:609-652-9409
Practice Address - Street 1:236 E. JIMMIE LEEDS ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-9599
Practice Address - Country:US
Practice Address - Phone:609-652-3933
Practice Address - Fax:609-652-9409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0263412081P2900X
NJ25MA068015208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJF97453Medicare UPIN
NJ093103Medicare PIN