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General NPI Number Information
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NPI Number | 1326477985
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Entity Type | Organization
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Legal Business Name | PROGRESSIVE PAIN MANAGEMENT LLC
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Dates
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Enumeration Date | 11/04/2013
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Last Update Date | 01/08/2021
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Provider Practice Location Address
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Address Line | 802 W PARK AVE STE 223
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City | OCEAN
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State | NJ
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Zip | 07712-8526
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Country | US
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Telephone | 732-493-2040
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Fax | 732-493-4582
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Provider Business Mailing Address
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Address Line | 802 W PARK AVE STE 223
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City | OCEAN
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State | NJ
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Zip | 07712-8526
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Country | US
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Telephone | 732-493-2040
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Fax | 732-493-4582
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Authorized Official
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Title or Position | CEO/MEMBER
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Name | DR. BRIAN ALWIN BANNISTER
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Credential | MD
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Telephone | 347-424-6157
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number | 25MA08847600
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License Number State | NJ
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