MEDICARE: NORTHLANDS ORTHOPAEDIC & SPORTS MEDICINE 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	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	25MA05626700	NJ

General Provider Information

NPI Number	:	1588740195
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHLANDS ORTHOPAEDIC & SPORTS MEDICINE PA

Provider Business Mailing Address
First Line	:	504 VALLEY RD
Second Line	:	SUITE 200
City	:	WAYNE
State	:	NJ
Zip	:	07470-3534
Country	:	US
Telephone Number	:	973-694-2690
Fax Number	:	973-694-2692

Provider Business Practice Location Address
First Line	:	504 VALLEY RD
Second Line	:	SUITE 200
City	:	WAYNE
State	:	NJ
Zip	:	07470-3534
Country	:	US
Telephone Number	:	973-694-2690
Fax Number	:	973-694-2692

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	VINCENT K MCINERNEY
Credential	:	MD
Telephone Number	:	973-694-2690

Provider Enumeration Date	:	10/27/2006
Last Update Date	:	04/04/2008

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