Healthcare Provider Details

I. General information

NPI: 1477937670
Provider Name (Legal Business Name): EASTERN STATES PAIN SPECIALISTS LIMITED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2015
Last Update Date: 07/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15000 MIDLANTIC DR STE 102
MOUNT LAUREL NJ
08054-1573
US

IV. Provider business mailing address

15000 MIDLANTIC DR STE 102
MOUNT LAUREL NJ
08054-1573
US

V. Phone/Fax

Practice location:
  • Phone: 856-255-5479
  • Fax: 856-393-8481
Mailing address:
  • Phone: 856-255-5479
  • Fax: 856-393-8481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number25MA08897600
License Number StateNJ

VIII. Authorized Official

Name: DR. SCOTT PELLO
Title or Position: MANAGING PARTNER
Credential: M.D.
Phone: 856-255-5479