Healthcare Provider Details

I. General information

NPI: 1962772483
Provider Name (Legal Business Name): NORTH JERSEY PRIMARY CARE & SPORTS MEDICINE INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2012
Last Update Date: 04/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 BRIGHTON ROAD SUITE 101
CLIFTON NJ
07012-1647
US

IV. Provider business mailing address

6 BRIGHTON ROAD SUITE 101
CLIFTON NJ
07012-1647
US

V. Phone/Fax

Practice location:
  • Phone: 973-340-1940
  • Fax: 973-340-1958
Mailing address:
  • Phone: 973-340-1940
  • Fax: 973-340-1958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number25MA08676900
License Number StateNJ

VIII. Authorized Official

Name: MICHAEL C RUSSONELLA
Title or Position: OWNER
Credential: DO
Phone: 973-340-1940