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General NPI Number Information
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NPI Number | 1023281284
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Entity Type | Organization
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Legal Business Name | NJ PAIN REHABILITATION GROUP, PC
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Dates
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Enumeration Date | 04/09/2008
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Last Update Date | 10/02/2008
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Provider Practice Location Address
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Address Line | 631 BROADWAY FIRST FLOOR
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City | BAYONNE
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State | NJ
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Zip | 07002
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Country | US
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Telephone | 973-751-2060
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Fax |
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Provider Business Mailing Address
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Address Line | 885 BROADWAY PMB168 PMB168
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City | BAYONNE
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State | NJ
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Zip | 07002
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Country | US
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Telephone | 973-751-2060
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Fax | 973-751-3334
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Authorized Official
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Title or Position | OWNER
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Name | DR. ANTONIO CICCONE
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Credential | DO
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Telephone | 973-751-2060
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | MB057523
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License Number State | NJ
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