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General NPI Number Information
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NPI Number | 1922435395
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Entity Type | Organization
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Legal Business Name | ADVANTAGE SPORTS MEDICINE LLC
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Dates
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Enumeration Date | 10/01/2013
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Last Update Date | 01/21/2014
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Provider Practice Location Address
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Address Line | 67 BROADWAY
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City | ELMWOOD PARK
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State | NJ
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Zip | 07407-1836
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Country | US
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Telephone | 201-569-0010
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 70176
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City | STATEN ISLAND
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State | NY
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Zip | 10307-0176
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Country | US
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Telephone | 718-984-4094
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Fax |
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Authorized Official
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Title or Position | OWNER/PHYSICIAN
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Name | THOMAS S BOTTIGLIERI
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Credential | D.O.
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Telephone | 201-569-0010
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | 25 MB07982100
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License Number State | NJ
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