Provider Demographics
NPI:1043457211
Name:PROFESSIONAL SPORTS MEDICINE ASSOCIATES L.L.C
Entity Type:Organization
Organization Name:PROFESSIONAL SPORTS MEDICINE ASSOCIATES L.L.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTTIGLIERI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:201-569-0010
Mailing Address - Street 1:PO BOX 70176
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10307-0176
Mailing Address - Country:US
Mailing Address - Phone:201-569-0010
Mailing Address - Fax:201-569-0080
Practice Address - Street 1:67 BROADWAY
Practice Address - Street 2:
Practice Address - City:ELMWOOD PARK
Practice Address - State:NJ
Practice Address - Zip Code:07407-1836
Practice Address - Country:US
Practice Address - Phone:201-569-0010
Practice Address - Fax:201-794-8411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-09
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ153031Medicare UPIN