Healthcare Provider Details

I. General information

NPI: 1023281284
Provider Name (Legal Business Name): NJ PAIN REHABILITATION GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 10/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 BROADWAY FIRST FLOOR
BAYONNE NJ
07002
US

IV. Provider business mailing address

885 BROADWAY PMB168 PMB168
BAYONNE NJ
07002
US

V. Phone/Fax

Practice location:
  • Phone: 973-751-2060
  • Fax:
Mailing address:
  • Phone: 973-751-2060
  • Fax: 973-751-3334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMB057523
License Number StateNJ

VIII. Authorized Official

Name: DR. ANTONIO CICCONE
Title or Position: OWNER
Credential: DO
Phone: 973-751-2060