Healthcare Provider Details

I. General information

NPI: 1720592942
Provider Name (Legal Business Name): PAIN ASSOCIATES OF BERGEN COUNTY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2017
Last Update Date: 05/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

294 STATE STREET SUITE 2
HACKENSACK NJ
07601
US

IV. Provider business mailing address

294 STATE ST SUITE 2
HACKENSACK NJ
07601
US

V. Phone/Fax

Practice location:
  • Phone: 201-525-0002
  • Fax:
Mailing address:
  • Phone: 201-488-7246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number25MA07161100
License Number StateNJ

VII. Legacy identifiers

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

VIII. Authorized Official

Name: SAMYADEV DATTA
Title or Position: OWNER
Credential: MD
Phone: 201-525-0002