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General NPI Number Information
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NPI Number | 1376087833
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Entity Type | Organization
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Legal Business Name | ANTHEM PAIN LLC
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Dates
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Enumeration Date | 12/16/2016
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Last Update Date | 12/16/2016
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Provider Practice Location Address
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Address Line | 1 YALE CT
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City | LIVINGSTON
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State | NJ
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Zip | 07039-1519
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Country | US
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Telephone | 973-941-2961
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 4224
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City | CLIFTON
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State | NJ
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Zip | 07012-8224
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Country | US
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Telephone | 973-941-2961
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. SHANTI EPPANAPALLY
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Credential | MD
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Telephone | 973-941-2961
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 25MA06866400
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License Number State | NJ
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