=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548491442
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORTHOPAEDIC SPINE SPECIALISTS OF NJ, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2009
-----------------------------------------------------
Last Update Date | 07/27/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1131 BROAD ST SUITE 201
-----------------------------------------------------
City | SHREWSBURY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07702-4329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-380-1212
-----------------------------------------------------
Fax | 732-380-1372
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1131 BROAD ST SUITE 201
-----------------------------------------------------
City | SHREWSBURY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07702-4329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-380-1212
-----------------------------------------------------
Fax | 732-380-1372
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER/OWNER
-----------------------------------------------------
Name | DR. STEVE J PARAGIOUDAKIS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 732-380-1212
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XS0117X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery of the Spine Physician
-----------------------------------------------------
License Number | 25MA06310200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------