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General NPI Number Information
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NPI Number | 1851580914
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Entity Type | Organization
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Legal Business Name | MILLENNIUM PAIN MANAGEMENT CENTER PA
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Dates
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Enumeration Date | 10/15/2007
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Last Update Date | 12/20/2010
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Provider Practice Location Address
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Address Line | 14 RIDGEDALE AVE SUITE 120
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City | CEDAR KNOLLS
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State | NJ
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Zip | 07927-1106
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Country | US
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Telephone | 973-219-2532
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 569
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City | DENVILLE
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State | NJ
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Zip | 07834-0569
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Country | US
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Telephone | 973-219-2532
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | GAMAL M DIAB
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Credential | M.D.
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Telephone | 973-219-2532
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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 | MA47466
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License Number State | NJ
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