Healthcare Provider Details

I. General information

NPI: 1275940306
Provider Name (Legal Business Name): ORTHOPAEDIC ASSOCIATES OF FAIR LAWN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2014
Last Update Date: 08/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 HARRISTOWN RD SUITE 103
GLEN ROCK NJ
07452-3329
US

IV. Provider business mailing address

85 HARRISTOWN RD SUITE 103
GLEN ROCK NJ
07452-3329
US

V. Phone/Fax

Practice location:
  • Phone: 844-366-8800
  • Fax:
Mailing address:
  • Phone: 844-366-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number25MA06309600
License Number StateNJ

VIII. Authorized Official

Name: BRYAN MASSOUD
Title or Position: PRESIDENT
Credential: MD
Phone: 844-366-8800