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General NPI Number Information
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NPI Number | 1639507684
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Entity Type | Organization
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Legal Business Name | GARDEN STATE ORTHOCARE LLC
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Dates
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Enumeration Date | 10/29/2013
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Last Update Date | 10/29/2013
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Provider Practice Location Address
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Address Line | 321 ESSEX ST
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City | HACKENSACK
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State | NJ
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Zip | 07601-2066
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Country | US
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Telephone | 888-721-6238
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Fax | 888-721-6238
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Provider Business Mailing Address
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Address Line | 68 BOULDER RIDGE RD
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City | SCARSDALE
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State | NY
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Zip | 10583-3150
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Country | US
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Telephone | 917-886-5545
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Fax | 718-795-9003
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. RANDALL VICTOR EHRLICH
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Credential | M.D.
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Telephone | 888-721-6238
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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 | 25MA09089400
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License Number State | NJ
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