=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497758296
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED INTERVENTIONAL PAIN MANAGEMENT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 BOULEVARD
-----------------------------------------------------
City | PASSAIC
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07055-2840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-365-4747
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 343
-----------------------------------------------------
City | MIDLAND PARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07432-0343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-804-2800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MICHAEL A REUVENI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 973-365-4747
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------