Healthcare Provider Details

I. General information

NPI: 1699228650
Provider Name (Legal Business Name): PERFORMANCE SPINE AND SPORTS MEDICINE EAST BRUNSWICK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2016
Last Update Date: 09/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 STATE ROUTE 18
EAST BRUNSWICK NJ
08816-3713
US

IV. Provider business mailing address

555 STATE ROUTE 18
EAST BRUNSWICK NJ
08816-3713
US

V. Phone/Fax

Practice location:
  • Phone: 609-817-0052
  • Fax:
Mailing address:
  • Phone: 609-817-0052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MA08922900
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MA09258600
License Number StateNJ

VIII. Authorized Official

Name: STACY SALERA
Title or Position: FINANCE REPRESENTATIVE
Credential:
Phone: 609-817-0052