Healthcare Provider Details

I. General information

NPI: 1528155561
Provider Name (Legal Business Name): ADVANCED SPORTS MEDICINE AND PT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 03/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 NEWARK POMPTON TPKE
RIVERDALE NJ
07457
US

IV. Provider business mailing address

18 NEWARK POMPTON TPKE
RIVERDALE NJ
07457
US

V. Phone/Fax

Practice location:
  • Phone: 973-616-4555
  • Fax: 973-616-3430
Mailing address:
  • Phone: 973-616-4555
  • Fax: 973-616-3430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number38MC00465700
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number38MC00465800
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number1285678045
License Number StateNJ
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01130300
License Number StateNJ
# 5
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01152400
License Number StateNJ
# 6
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number46TR00647900
License Number StateNJ

VIII. Authorized Official

Name: DR. CHRISTINE CARMEAN FOSS
Title or Position: CO OWNER
Credential: DC
Phone: 973-616-4555