Healthcare Provider Details

I. General information

NPI: 1346296969
Provider Name (Legal Business Name): SPORTS EXTRA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 10/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 WALNUT AVE SUITE 202
CLARK NJ
07066-1640
US

IV. Provider business mailing address

67 WALNUT AVE SUITE 202
CLARK NJ
07066-1640
US

V. Phone/Fax

Practice location:
  • Phone: 732-388-7300
  • Fax: 732-388-1330
Mailing address:
  • Phone: 732-388-7300
  • Fax: 732-388-1330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHELE THERESA GILSENAN
Title or Position: PRACTICE OWNER
Credential: D.O.
Phone: 732-388-7300