MEDICARE: NEW JERSEY INSTITUTE FOR MINIMALLY INVASIVE SPINE CARE, 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	174400000X	Specialist	MAO40008	NJ

General Provider Information

NPI Number	:	1417123621
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW JERSEY INSTITUTE FOR MINIMALLY INVASIVE SPINE CARE, PA

Provider Business Mailing Address
First Line	:	300 MAIN ST
Second Line	:	21 MADISON PLAZA #107
City	:	MADISON
State	:	NJ
Zip	:	07940-2369
Country	:	US
Telephone Number	:	973-736-7300
Fax Number	:	973-736-7322

Provider Business Practice Location Address
First Line	:	345 MAIN ST
Second Line	:
City	:	WEST ORANGE
State	:	NJ
Zip	:	07052-5700
Country	:	US
Telephone Number	:	973-736-7300
Fax Number	:	973-736-7322

Authorized Official
Title or Position	:	DIRECTOR/OWNER
Name	:	DR. SRI KANTHA
Credential	:	MD
Telephone Number	:	973-736-7300

Provider Enumeration Date	:	05/07/2008
Last Update Date	:	05/07/2008

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