MEDICARE: ORTHOPAEDIC ASSOCIATES OF FAIR LAWN, LLC

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
1	207XX0801X	Orthopaedic Trauma Physician	25MA06309600	NJ

General Provider Information

NPI Number	:	1275940306
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORTHOPAEDIC ASSOCIATES OF FAIR LAWN, LLC

Provider Business Mailing Address
First Line	:	85 HARRISTOWN RD
Second Line	:	SUITE 103
City	:	GLEN ROCK
State	:	NJ
Zip	:	07452-3329
Country	:	US
Telephone Number	:	844-366-8800
Fax Number	:

Provider Business Practice Location Address
First Line	:	85 HARRISTOWN RD
Second Line	:	SUITE 103
City	:	GLEN ROCK
State	:	NJ
Zip	:	07452-3329
Country	:	US
Telephone Number	:	844-366-8800
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRYAN MASSOUD
Credential	:	MD
Telephone Number	:	844-366-8800

Provider Enumeration Date	:	07/21/2014
Last Update Date	:	08/23/2016

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