Healthcare Provider Details

I. General information

NPI: 1588686604
Provider Name (Legal Business Name): SOUTH JERSEY SPORTS & SPINE MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 10/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 ROUTE 73 SOUTH EVESHAM COMMONS- SUITE 104A
MARLTON NJ
08053-9643
US

IV. Provider business mailing address

PO BOX 22462
PHILADELPHIA PA
19110-2462
US

V. Phone/Fax

Practice location:
  • Phone: 856-874-9777
  • Fax: 856-874-9444
Mailing address:
  • Phone: 215-732-7600
  • Fax: 856-874-9444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: MERYL Y STEIN
Title or Position: OWNER
Credential: MD
Phone: 856-874-9777