=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588279509
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPINE AND PAIN RELIEF CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2020
-----------------------------------------------------
Last Update Date | 09/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 924 BROADWAY
-----------------------------------------------------
City | BAYONNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07002-2155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-243-6211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 924 BROADWAY
-----------------------------------------------------
City | BAYONNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07002-2155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-243-6211
-----------------------------------------------------
Fax | 201-455-2422
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DOCTOR
-----------------------------------------------------
Name | RAED HATTAB
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 917-651-3629
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP3300X
-----------------------------------------------------
Taxonomy Name | Pain Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------