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NPI Code Detail

MEDICARE: ADVANTAGE SPORTS MEDICINE LLC

MEDICARE: ADVANTAGE SPORTS MEDICINE 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
1261QM1300XMulti-Specialty Clinic/Center25 MB07982100NJ

General Provider Information

NPI Number : 1922435395
Entity Type Code : Organization
Provider Name (Legal Business Name) : ADVANTAGE SPORTS MEDICINE LLC
Provider Business Mailing Address
First Line : PO BOX 70176
Second Line :
City : STATEN ISLAND
State : NY
Zip : 10307-0176
Country : US
Telephone Number : 718-984-4094
Fax Number :
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 :
Authorized Official
Title or Position : OWNER/PHYSICIAN
Name : THOMAS S BOTTIGLIERI
Credential : D.O.
Telephone Number : 201-569-0010
Provider Enumeration Date : 10/01/2013
Last Update Date : 01/21/2014

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Directions to “ADVANTAGE SPORTS MEDICINE LLC ” Practice Location

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