Healthcare Provider Details

I. General information

NPI: 1396105516
Provider Name (Legal Business Name): CENTER FOR PAIN AND REGENERATIVE MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2016
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 E MAIN ST
RAMSEY NJ
07446-1902
US

IV. Provider business mailing address

255 E MAIN ST
RAMSEY NJ
07446-1902
US

V. Phone/Fax

Practice location:
  • Phone: 201-391-4700
  • Fax:
Mailing address:
  • Phone: 201-391-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number0400394178
License Number StateNJ

VIII. Authorized Official

Name: DAVID GAMBURG
Title or Position: CEO
Credential: M.D.
Phone: 201-391-4700