Provider Demographics
NPI:1962642876
Name:PARK AVENUE PAIN MANAGEMENT
Entity Type:Organization
Organization Name:PARK AVENUE PAIN MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DITACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PRAMILA
Authorized Official - Middle Name:
Authorized Official - Last Name:BYAHATTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-279-8462
Mailing Address - Street 1:P.O.BOX 959
Mailing Address - Street 2:
Mailing Address - City:SOUTH PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07080-5530
Mailing Address - Country:US
Mailing Address - Phone:908-279-8462
Mailing Address - Fax:732-605-1238
Practice Address - Street 1:2509 PARK AVE
Practice Address - Street 2:SUITE 1A
Practice Address - City:SOUTH PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07080-5300
Practice Address - Country:US
Practice Address - Phone:908-279-8462
Practice Address - Fax:732-605-1238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-05
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04131700207L00000X
NJMA030896207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty