Healthcare Provider Details

I. General information

NPI: 1609311398
Provider Name (Legal Business Name): NORTH JERSEY SPORTS MEDICINE AND ORTHOPEDIC CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2017
Last Update Date: 01/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 BILBY RD SUITE 201
HACKETTSTOWN NJ
07840-4174
US

IV. Provider business mailing address

108 BILBY RD SUITE 201
HACKETTSTOWN NJ
07840-4174
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 TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00420400
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number25MP00420400
License Number StateNJ

VIII. Authorized Official

Name: DR. ROBERT A DEFALCO JR.
Title or Position: MANAGING PARTNER
Credential: DO
Phone: 908-684-3005