Healthcare Provider Details

I. General information

NPI: 1225680796
Provider Name (Legal Business Name): NJ INTERVENTIONAL PAIN MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2019
Last Update Date: 11/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 HUDSON ST STE 301
HACKENSACK NJ
07601-6655
US

IV. Provider business mailing address

560 HUDSON ST STE 301
HACKENSACK NJ
07601-6655
US

V. Phone/Fax

Practice location:
  • Phone: 201-641-2125
  • Fax: 201-630-8831
Mailing address:
  • Phone: 201-641-2125
  • Fax: 201-630-8831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0450398638
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerBUSINESS REGISTRATION

VIII. Authorized Official

Name: FENAR THEMISTOCLE
Title or Position: OWNER
Credential: MD
Phone: 201-630-8831