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NPI Code Detail

MEDICARE: PROFESSIONAL SPORTS MEDICINE ASSOCIATES L.L.C

MEDICARE: PROFESSIONAL SPORTS MEDICINE ASSOCIATES L.L.C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207QS0010XSports Medicine (Family Medicine) Physician

General Provider Information

NPI Number : 1043457211
Entity Type Code : Organization
Provider Name (Legal Business Name) : PROFESSIONAL SPORTS MEDICINE ASSOCIATES L.L.C
Provider Business Mailing Address
First Line : PO BOX 70176
Second Line :
City : STATEN ISLAND
State : NY
Zip : 10307-0176
Country : US
Telephone Number : 201-569-0010
Fax Number : 201-569-0080
Provider Business Practice Location Address
First Line : 67 BROADWAY
Second Line :
City : ELMWOOD PARK
State : NJ
Zip : 07407-1836
Country : US
Telephone Number : 201-569-0010
Fax Number : 201-794-8411
Authorized Official
Title or Position : PRESIDENT
Name : DR. THOMAS BOTTIGLIERI
Credential : D.O.
Telephone Number : 201-569-0010
Provider Enumeration Date : 01/09/2009
Last Update Date : 02/11/2013

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