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General NPI Number Information
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NPI Number | 1194036111
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Entity Type | Organization
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Legal Business Name | PROFESSIONAL PAIN MANAGEMENT SERVICES PA
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Dates
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Enumeration Date | 06/24/2010
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Last Update Date | 06/24/2010
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Provider Practice Location Address
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Address Line | 1060 CLIFTON AVE
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City | CLIFTON
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State | NJ
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Zip | 07013-3638
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Country | US
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Telephone | 973-779-7361
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Fax | 973-779-7385
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Provider Business Mailing Address
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Address Line | PO BOX 1258
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City | CLIFTON
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State | NJ
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Zip | 07012-0758
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Country | US
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Telephone | 973-779-7361
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Fax | 973-779-7385
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Authorized Official
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Title or Position | CEO
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Name | DR. RAVI K VENKATARAMAN
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Credential | MD
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Telephone | 973-779-7361
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number | 25MA06850700
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License Number State | NJ
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