Healthcare Provider Details

I. General information

NPI: 1649469081
Provider Name (Legal Business Name): SPINE ORTHOPEDIC AND SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2007
Last Update Date: 10/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1084 MAIN AVE
CLIFTON NJ
07011-2330
US

IV. Provider business mailing address

1084 MAIN AVE
CLIFTON NJ
07011-2330
US

V. Phone/Fax

Practice location:
  • Phone: 973-470-8848
  • Fax: 973-470-8826
Mailing address:
  • Phone: 973-470-8848
  • Fax: 973-470-8826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MA06785400
License Number StateNJ

VIII. Authorized Official

Name: MIRZA BEG
Title or Position: DIRECTOR
Credential: MD
Phone: 973-470-8848