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General NPI Number Information
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NPI Number | 1962772483
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Entity Type | Organization
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Legal Business Name | NORTH JERSEY PRIMARY CARE & SPORTS MEDICINE INSTITUTE LLC
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Dates
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Enumeration Date | 01/02/2012
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Last Update Date | 04/04/2016
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Provider Practice Location Address
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Address Line | 6 BRIGHTON ROAD SUITE 101
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City | CLIFTON
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State | NJ
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Zip | 07012-1647
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Country | US
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Telephone | 973-340-1940
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Fax | 973-340-1958
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Provider Business Mailing Address
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Address Line | 6 BRIGHTON ROAD SUITE 101
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City | CLIFTON
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State | NJ
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Zip | 07012-1647
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Country | US
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Telephone | 973-340-1940
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Fax | 973-340-1958
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Authorized Official
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Title or Position | OWNER
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Name | MICHAEL C RUSSONELLA
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Credential | DO
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Telephone | 973-340-1940
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 25MA08676900
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License Number State | NJ
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