Healthcare Provider Details

I. General information

NPI: 1609272095
Provider Name (Legal Business Name): RECONSTRUCTIVE ORTHOPEDICS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2014
Last Update Date: 11/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 YOUNG AVE SUITE 245
MOORESTOWN NJ
08057-3130
US

IV. Provider business mailing address

4 EVES DR # A SUITE 100
MARLTON NJ
08053-3195
US

V. Phone/Fax

Practice location:
  • Phone: 609-267-9400
  • Fax:
Mailing address:
  • Phone: 609-267-9400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: AMY MICKLE
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 609-267-9400