Provider Demographics
NPI:1821580747
Name:GARDEN STATE SPORTS & PAIN MEDICINE, LLC
Entity Type:Organization
Organization Name:GARDEN STATE SPORTS & PAIN MEDICINE, LLC
Other - Org Name:PREMIER PAIN AND SPINE SOLUTIONS, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:S
Authorized Official - Last Name:KOPPEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:914-666-8866
Mailing Address - Street 1:480 BEDFORD RD STE 4202
Mailing Address - Street 2:
Mailing Address - City:CHAPPAQUA
Mailing Address - State:NY
Mailing Address - Zip Code:10514-1716
Mailing Address - Country:US
Mailing Address - Phone:914-666-8866
Mailing Address - Fax:
Practice Address - Street 1:721 CLIFTON AVE STE 2D
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-1880
Practice Address - Country:US
Practice Address - Phone:914-666-8866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-06
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty