Healthcare Provider Details

I. General information

NPI: 1598712556
Provider Name (Legal Business Name): ORTHOPEDIC SURGERY & SPORTS MEDICINE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 12/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 BEAVERBROOK RD STE 201
LINCOLN PARK NJ
07035-1748
US

IV. Provider business mailing address

61 BEAVERBROOK RD STE 201
LINCOLN PARK NJ
07035-1748
US

V. Phone/Fax

Practice location:
  • Phone: 973-616-0200
  • Fax: 973-696-9294
Mailing address:
  • Phone: 973-616-0200
  • Fax: 973-696-9294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number43990
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number62817
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number64376
License Number StateNJ

VIII. Authorized Official

Name: MRS. JEANNETTE BOTERO
Title or Position: OFFICE MANAGER
Credential:
Phone: 973-616-0200