Healthcare Provider Details

I. General information

NPI: 1700944147
Provider Name (Legal Business Name): WATERFRONT INSTITUTE FOR SPINE AND JOINT REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 10/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 RIVER RD STE 901
EDGEWATER NJ
07020-1080
US

IV. Provider business mailing address

115 RIVER RD STE 901
EDGEWATER NJ
07020-1080
US

V. Phone/Fax

Practice location:
  • Phone: 201-840-1980
  • Fax: 201-840-1987
Mailing address:
  • Phone: 201-840-1980
  • Fax: 201-840-1987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID P PODELL
Title or Position: PRESIDENT
Credential: D. C.
Phone: 201-840-1980