MEDICARE: PAIN MEDICINE AND ANESTHESIA PC

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	207LP2900X	Pain Medicine (Anesthesiology) Physician	25MB07566200	NJ

General Provider Information

NPI Number	:	1386925394
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAIN MEDICINE AND ANESTHESIA PC

Provider Business Mailing Address
First Line	:	387 VANCE AVE
Second Line	:
City	:	FRANKLIN LAKES
State	:	NJ
Zip	:	07417-3016
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	387 VANCE AVE
Second Line	:
City	:	FRANKLIN LAKES
State	:	NJ
Zip	:	07417-3016
Country	:	US
Telephone Number	:	201-945-2900
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROMAN KOSIBOROD
Credential	:	D.O.
Telephone Number	:	201-945-2900

Provider Enumeration Date	:	09/02/2011
Last Update Date	:	09/02/2011

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