Healthcare Provider Details

I. General information

NPI: 1043457211
Provider Name (Legal Business Name): PROFESSIONAL SPORTS MEDICINE ASSOCIATES L.L.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2009
Last Update Date: 02/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 BROADWAY
ELMWOOD PARK NJ
07407-1836
US

IV. Provider business mailing address

PO BOX 70176
STATEN ISLAND NY
10307-0176
US

V. Phone/Fax

Practice location:
  • Phone: 201-569-0010
  • Fax: 201-794-8411
Mailing address:
  • Phone: 201-569-0010
  • Fax: 201-569-0080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. THOMAS BOTTIGLIERI
Title or Position: PRESIDENT
Credential: D.O.
Phone: 201-569-0010