=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023445699
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHEAST PAIN MANAGEMENT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2013
-----------------------------------------------------
Last Update Date | 09/27/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 MARKET ST. #1C
-----------------------------------------------------
City | CAMDEN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-558-2732
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 MARKET ST. #1C
-----------------------------------------------------
City | CAMDEN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DOCTOR
-----------------------------------------------------
Name | CHANG H. LEE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-558-2732
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 25MA05757200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------