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General NPI Number Information
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NPI Number | 1225409980
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Entity Type | Organization
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Legal Business Name | EASTERN STATES PAIN SPECIALISTS, LLC
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Dates
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Enumeration Date | 10/07/2015
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Last Update Date | 10/07/2015
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Provider Practice Location Address
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Address Line | 15000 MIDLANTIC DR
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City | MOUNT LAUREL
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State | NJ
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Zip | 08054-1573
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Country | US
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Telephone | 856-855-5479
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 4604
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City | LANCASTER
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State | PA
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Zip | 17604-4604
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Country | US
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Telephone | 201-804-2800
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Fax | 201-804-8883
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL
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Name | JEFFREY GORDON
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Credential | M.D.
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Telephone | 201-667-5568
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208VP0000X
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Taxonomy Name | Pain Medicine Physician
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License Number |
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License Number State |
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