MEDICARE: SPINE AND PAIN SPECIALTY CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207LP2900X	Pain Medicine (Anesthesiology) Physician

General Provider Information

NPI Number	:	1881090413
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPINE AND PAIN SPECIALTY CARE LLC

Provider Business Mailing Address
First Line	:	219 S BROAD ST
Second Line	:
City	:	ELIZABETH
State	:	NJ
Zip	:	07202-3453
Country	:	US
Telephone Number	:	908-818-1600
Fax Number	:	908-818-1601

Provider Business Practice Location Address
First Line	:	219 S BROAD ST
Second Line	:
City	:	ELIZABETH
State	:	NJ
Zip	:	07202-3453
Country	:	US
Telephone Number	:	908-818-1600
Fax Number	:	908-818-1601

Authorized Official
Title or Position	:	PAIN PHYSICIAN
Name	:	EDWARD SHEN
Credential	:	MD
Telephone Number	:	908-818-1600

Provider Enumeration Date	:	11/10/2014
Last Update Date	:	07/25/2016

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