Healthcare Provider Details

I. General information

NPI: 1619025038
Provider Name (Legal Business Name): NORTH JERSEY SPORTS MEDICINE AND ORTHOPEDIC CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 11/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 BILBY ROAD SUITE 201
HACKETTSTOWN NJ
07840
US

IV. Provider business mailing address

108 BILBY ROAD SUITE 201
HACKETTSTOWN NJ
07840
US

V. Phone/Fax

Practice location:
  • Phone: 908-684-3005
  • Fax: 908-684-3301
Mailing address:
  • Phone: 908-684-3005
  • Fax: 908-684-3301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MB06992500
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MB06971100
License Number StateNJ

VIII. Authorized Official

Name: DOREE VANDENBERGH
Title or Position: CREDENTIALER/DIRECTOR
Credential:
Phone: 908-684-3005