Provider Demographics
NPI:1578886180
Name:SUSSEX PAIN RELIEF CENTER LLC
Entity Type:Organization
Organization Name:SUSSEX PAIN RELIEF CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MANONMANI
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTONY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-519-0100
Mailing Address - Street 1:18229 DUPONT BLVD
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19947-3127
Mailing Address - Country:US
Mailing Address - Phone:302-514-7246
Mailing Address - Fax:302-253-8028
Practice Address - Street 1:18229 DUPONT BLVD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:DE
Practice Address - Zip Code:19947
Practice Address - Country:US
Practice Address - Phone:302-519-1616
Practice Address - Fax:302-253-8028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-10
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE207L00000X, 208100000X, 208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1578886180Medicaid
DE1578886180Medicaid