Healthcare Provider Details

I. General information

NPI: 1023388980
Provider Name (Legal Business Name): ACTIVE ORTHOPEDIC SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2012
Last Update Date: 06/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 PROSPECT AVE
HACKENSACK NJ
07601-1960
US

IV. Provider business mailing address

25 PROSPECT AVE
HACKENSACK NJ
07601-1960
US

V. Phone/Fax

Practice location:
  • Phone: 201-343-2277
  • Fax: 201-343-7410
Mailing address:
  • Phone: 201-343-2277
  • Fax: 201-343-7410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number25MA05362900
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. MICHAEL L GROSS
Title or Position: OWNER
Credential: MD
Phone: 201-343-2277