Healthcare Provider Details

I. General information

NPI: 1669784773
Provider Name (Legal Business Name): HEALTHSPINE AND ANESTHESIA INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2010
Last Update Date: 02/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 HATFIELD LN
GOSHEN NY
10924-6734
US

IV. Provider business mailing address

PO BOX 4
CEDAR KNOLLS NJ
07927-0004
US

V. Phone/Fax

Practice location:
  • Phone: 973-865-5111
  • Fax: 201-939-1701
Mailing address:
  • Phone: 973-865-5111
  • Fax: 201-939-1701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: TOMI T PRVULOVIC
Title or Position: OWNER
Credential: MD
Phone: 973-865-5111