=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649469081
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPINE ORTHOPEDIC AND SPORTS MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2007
-----------------------------------------------------
Last Update Date | 10/22/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1084 MAIN AVE
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07011-2330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-470-8848
-----------------------------------------------------
Fax | 973-470-8826
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1084 MAIN AVE
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07011-2330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-470-8848
-----------------------------------------------------
Fax | 973-470-8826
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MIRZA BEG
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 973-470-8848
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 25MA06785400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------