MEDICARE: TRI-COUNTY PAIN MANAGEMENT & REHABILITATION, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician

General Provider Information

NPI Number	:	1194760801
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRI-COUNTY PAIN MANAGEMENT & REHABILITATION, PA

Provider Business Mailing Address
First Line	:	PO BOX 43776
Second Line	:
City	:	UPPER MONTCLAIR
State	:	NJ
Zip	:	07043-0776
Country	:	US
Telephone Number	:	201-804-2800
Fax Number	:

Provider Business Practice Location Address
First Line	:	206 BERGEN AVE
Second Line	:
City	:	KEARNY
State	:	NJ
Zip	:	07032-3324
Country	:	US
Telephone Number	:	201-955-7000
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PHILIP LUTZ
Credential	:	MD
Telephone Number	:	208-042-8008

Provider Enumeration Date	:	06/17/2006
Last Update Date	:	07/12/2007

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