Provider Demographics
NPI:1891004685
Name:EASTERN REGIONAL PAIN MGT
Entity Type:Organization
Organization Name:EASTERN REGIONAL PAIN MGT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PAIN DOCTOR ANESTHESIOLOGY/PAIN MAN
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:P
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:215-945-8882
Mailing Address - Street 1:333. S. OXFORD VALLEY RD.
Mailing Address - Street 2:STE 606
Mailing Address - City:FAIRLESS HILLS
Mailing Address - State:PA
Mailing Address - Zip Code:19030
Mailing Address - Country:US
Mailing Address - Phone:215-945-8882
Mailing Address - Fax:215-945-9129
Practice Address - Street 1:151 FRIES MILL RD.
Practice Address - Street 2:
Practice Address - City:TURNERSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08012
Practice Address - Country:US
Practice Address - Phone:215-945-8882
Practice Address - Fax:215-945-9129
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EASTERN REGIONAL PAIN MANAGEMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-28
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA05005840L207LP2900X
NJMB50806207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ052633Medicare PIN
PA564403Medicare PIN
E23610Medicare UPIN