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General NPI Number Information
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NPI Number | 1326282088
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Entity Type | Organization
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Legal Business Name | PERFORMANCE ORTHOPAEDICS & SPORTS MEDICINE, LLC
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Dates
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Enumeration Date | 04/26/2009
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Last Update Date | 02/20/2017
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Provider Practice Location Address
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Address Line | 780 ROUTE 37 W STE 330
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City | TOMS RIVER
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State | NJ
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Zip | 08755-5064
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Country | US
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Telephone | 732-691-4898
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Fax | 732-608-8950
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Provider Business Mailing Address
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Address Line | 780 ROUTE 37 W STE 330
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City | TOMS RIVER
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State | NJ
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Zip | 08755-5064
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Country | US
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Telephone | 732-691-4898
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Fax | 732-608-8950
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Authorized Official
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Title or Position | OWNER
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Name | DR. DAVID DICKERSON
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Credential | M.D.
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Telephone | 732-567-7350
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207XX0005X
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Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
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License Number | 25MA07911500
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License Number State | NJ
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