Healthcare Provider Details

I. General information

NPI: 1093111916
Provider Name (Legal Business Name): PAIN AND NEUROPATHY CENTER OF PA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2014
Last Update Date: 11/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 PENNSYLVANIA AVE
MATAMORAS PA
18336-1541
US

IV. Provider business mailing address

905 PENNSYLVANIA AVE
MATAMORAS PA
18336-1541
US

V. Phone/Fax

Practice location:
  • Phone: 570-431-6464
  • Fax: 973-206-2236
Mailing address:
  • Phone: 570-431-6464
  • Fax: 973-206-2236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberMD423585
License Number StatePA

VIII. Authorized Official

Name: DR. AJAY KUMAR
Title or Position: PRESIDENT
Credential: M.D.
Phone: 570-431-6464