=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912058546
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRAL JERSEY SPINE ASSOCIATES, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 123 FRANKLIN CORNER RD SUITE 109
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08648-2526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-896-3131
-----------------------------------------------------
Fax | 609-896-4103
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 123 FRANKLIN CORNER RD SUITE 109
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08648-2526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-896-3131
-----------------------------------------------------
Fax | 609-896-4103
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JOHN DANIEL TYDINGS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 609-896-3131
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XS0117X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery of the Spine Physician
-----------------------------------------------------
License Number | 25MA05466300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------