Provider Demographics
NPI:1073912333
Name:PERFORMANCE SPINE AND SPORTS MEDICINE OF BORDENTOWN, LLC
Entity Type:Organization
Organization Name:PERFORMANCE SPINE AND SPORTS MEDICINE OF BORDENTOWN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHIAS
Authorized Official - Middle Name:HEINZ
Authorized Official - Last Name:WIEDERHOLZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-588-8600
Mailing Address - Street 1:9500 K. JOHNSON BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BORDENTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08505-4400
Mailing Address - Country:US
Mailing Address - Phone:609-588-8600
Mailing Address - Fax:609-588-8602
Practice Address - Street 1:9500 K. JOHNSON BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:BORDENTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08505-4400
Practice Address - Country:US
Practice Address - Phone:609-588-8600
Practice Address - Fax:609-588-8602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-22
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08436100332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies