Healthcare Provider Details

I. General information

NPI: 1639507684
Provider Name (Legal Business Name): GARDEN STATE ORTHOCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 10/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 ESSEX ST
HACKENSACK NJ
07601-2066
US

IV. Provider business mailing address

68 BOULDER RIDGE RD
SCARSDALE NY
10583-3150
US

V. Phone/Fax

Practice location:
  • Phone: 888-721-6238
  • Fax: 888-721-6238
Mailing address:
  • Phone: 917-886-5545
  • Fax: 718-795-9003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number25MA09089400
License Number StateNJ

VIII. Authorized Official

Name: DR. RANDALL VICTOR EHRLICH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 888-721-6238