=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093257776
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHILADELPHIA SMART PAIN & WELLNESS, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2016
-----------------------------------------------------
Last Update Date | 03/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 BALA AVE STE LL3
-----------------------------------------------------
City | BALA CYNWYD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19004-3218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-366-2803
-----------------------------------------------------
Fax | 267-337-7950
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 597
-----------------------------------------------------
City | WEST DEPTFORD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08086-0597
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-366-2803
-----------------------------------------------------
Fax | 267-337-7950
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SAMUEL ROBERT GRODOFSKY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 215-366-2803
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------