Basic Information
| Provider Information | |||||||||
| NPI: | 1376572875 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BACK | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | MARC | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 285 DAVIDSON AVE | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | SOMERSET | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088734153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322711400 | ||||||||
| FaxNumber: | 7322713544 | ||||||||
| Practice Location | |||||||||
| Address1: | 285 DAVIDSON AVE | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | SOMERSET | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088734153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322711400 | ||||||||
| FaxNumber: | 7322713544 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 12/14/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | A78879 | CA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 25MA09723700 | NJ | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00A788790 | 05 | CA | MEDICAID |