Healthcare Provider Details

I. General information

NPI: 1861731036
Provider Name (Legal Business Name): KM SPORTS AND SPINE MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2013
Last Update Date: 01/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 MARKET ST
SADDLE BROOK NJ
07663-5996
US

IV. Provider business mailing address

444 MARKET ST SUITE 2B
SADDLE BROOK NJ
07663-5996
US

V. Phone/Fax

Practice location:
  • Phone: 201-632-3080
  • Fax: 201-644-6269
Mailing address:
  • Phone: 201-632-3080
  • Fax: 201-644-6269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number25MB08770900
License Number StateNJ

VIII. Authorized Official

Name: DR. KEVIN MCELROY
Title or Position: PRESIDENT
Credential: DO
Phone: 201-632-3080