Healthcare Provider Details

I. General information

NPI: 1265754832
Provider Name (Legal Business Name): SPECIALIZED SPINE SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2010
Last Update Date: 03/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 CHANTICLEER DRIVE
CHERRY HILL NJ
08003-4813
US

IV. Provider business mailing address

PO BOX 1752
BRIDGETON NJ
08302-0472
US

V. Phone/Fax

Practice location:
  • Phone: 856-451-9395
  • Fax: 856-451-8615
Mailing address:
  • Phone: 856-451-9395
  • Fax: 856-451-8615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: HELEN G PILLA
Title or Position: DIRECTOR
Credential:
Phone: 856-451-9395