Provider Demographics
NPI:1689142622
Name:REGENESPINE, LLC
Entity Type:Organization
Organization Name:REGENESPINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-570-6980
Mailing Address - Street 1:1230 WHITEHORSE MERCERVILLE RD STE C
Mailing Address - Street 2:
Mailing Address - City:MERCERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08619-3838
Mailing Address - Country:US
Mailing Address - Phone:609-570-6980
Mailing Address - Fax:609-228-5060
Practice Address - Street 1:1230 WHITEHORSE MERCERVILLE RD STE C
Practice Address - Street 2:
Practice Address - City:MERCERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08619-3838
Practice Address - Country:US
Practice Address - Phone:609-570-6980
Practice Address - Fax:877-732-7317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-07
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0111953Medicaid