MEDICARE: NEW JERSEY ORTHOPEDIC AND SPORTS MEDICINE L.L.C.

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	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician

General Provider Information

NPI Number	:	1518492289
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW JERSEY ORTHOPEDIC AND SPORTS MEDICINE L.L.C.

Provider Business Mailing Address
First Line	:	24 MERCHANT ST
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07105-2847
Country	:	US
Telephone Number	:	973-344-4787
Fax Number	:

Provider Business Practice Location Address
First Line	:	99 MADISON ST
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07105-2107
Country	:	US
Telephone Number	:	973-334-4787
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	DR. MARK L BRANDON
Credential	:
Telephone Number	:	973-334-4787

Provider Enumeration Date	:	05/01/2017
Last Update Date	:	05/01/2017

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