Healthcare Provider Details

I. General information

NPI: 1386758423
Provider Name (Legal Business Name): PREMIER ORTHOPAEDICS &SPORTS MEDICINE,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 12/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

663 PALISADE AVE SUITE 302
CLIFFSIDE PARK NJ
07010-3012
US

IV. Provider business mailing address

111 GALWAY PL
TEANECK NJ
07666-3606
US

V. Phone/Fax

Practice location:
  • Phone: 201-943-9100
  • Fax: 201-943-7308
Mailing address:
  • Phone: 201-833-9500
  • Fax: 201-862-0095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: HOWARD M BARUCH
Title or Position: PRESIDENT
Credential: MD
Phone: 201-833-9500