Healthcare Provider Details

I. General information

NPI: 1194904730
Provider Name (Legal Business Name): EAST COAST SPINE JOINT AND SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2007
Last Update Date: 09/19/2022
Certification Date: 02/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 MONROE STREET SUITE C-208
HOBOKEN NJ
07030-5000
US

IV. Provider business mailing address

720 MONROE STREET SUITE C-208
HOBOKEN NJ
07030-5000
US

V. Phone/Fax

Practice location:
  • Phone: 201-533-9200
  • Fax:
Mailing address:
  • Phone: 201-533-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number38MC00542700
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number25MA07808900
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number25MA07808900
License Number StateNJ

VIII. Authorized Official

Name: DR. ALEXANDER J VISCO
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 201-533-9200