Healthcare Provider Details

I. General information

NPI: 1265488902
Provider Name (Legal Business Name): GARDEN STATE PAIN MANAGEMENT, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 10/22/2023
Certification Date: 10/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1033 CLIFTON AVE STE 209
CLIFTON NJ
07013-3525
US

IV. Provider business mailing address

1033 CLIFTON AVE STE 209
CLIFTON NJ
07013-3525
US

V. Phone/Fax

Practice location:
  • Phone: 973-473-5752
  • Fax: 973-473-2459
Mailing address:
  • Phone: 973-473-5752
  • Fax: 973-473-2459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: TODD S. KOPPEL
Title or Position: PRESIDENT
Credential: MD
Phone: 973-473-5752