Provider Demographics
NPI:1003279506
Name:ADVANCED SPINE AND PAIN CENTER LLC
Entity type:Organization
Organization Name:ADVANCED SPINE AND PAIN CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUKDEB
Authorized Official - Middle Name:
Authorized Official - Last Name:DATTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-479-4692
Mailing Address - Street 1:1 TREETOP CT
Mailing Address - Street 2:
Mailing Address - City:BERKELEY HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:07922
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1060 BROAD STREET
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102
Practice Address - Country:US
Practice Address - Phone:615-472-4692
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08823500261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
H20467Medicare UPIN