=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376526780
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEFFERSON PAIN AND REHAB CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4735 CLAIRTON BLVD
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15236-2115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-885-5400
-----------------------------------------------------
Fax | 412-885-1773
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4735 CLAIRTON BLVD
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15236-2115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-885-5400
-----------------------------------------------------
Fax | 412-885-1773
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIR JEFFERSON PAIN & REHAB
-----------------------------------------------------
Name | JOHN KEUN-SANG LEE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 412-885-5400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | MD037447Y
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------