Healthcare Provider Details

I. General information

NPI: 1063858223
Provider Name (Legal Business Name): HAWTHORNE PAIN & SPINE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2013
Last Update Date: 01/27/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 LAFAYETTE AVE
HAWTHORNE NJ
07506-1904
US

IV. Provider business mailing address

219 LAFAYETTE AVE
HAWTHORNE NJ
07506-1904
US

V. Phone/Fax

Practice location:
  • Phone: 973-423-9100
  • Fax: 973-423-1339
Mailing address:
  • Phone: 973-423-9100
  • Fax: 973-423-1339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: PETER BERGER
Title or Position: MANAGING MEMBER
Credential: DC
Phone: 973-423-9100