Healthcare Provider Details

I. General information

NPI: 1922435395
Provider Name (Legal Business Name): ADVANTAGE SPORTS MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2013
Last Update Date: 01/21/2014
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:
Mailing address:
  • Phone: 718-984-4094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number25 MB07982100
License Number StateNJ

VIII. Authorized Official

Name: THOMAS S BOTTIGLIERI
Title or Position: OWNER/PHYSICIAN
Credential: D.O.
Phone: 201-569-0010