Provider Demographics
NPI:1073937579
Name:NORTHEAST ORTHOPEDICS AND SPORTS MEDICINE PLLC
Entity Type:Organization
Organization Name:NORTHEAST ORTHOPEDICS AND SPORTS MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MBR
Authorized Official - Prefix:DR
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-262-5313
Mailing Address - Street 1:507 AIRPORT EXECUTIVE PARK
Mailing Address - Street 2:
Mailing Address - City:NANUET
Mailing Address - State:NY
Mailing Address - Zip Code:10954-5238
Mailing Address - Country:US
Mailing Address - Phone:845-262-5313
Mailing Address - Fax:845-262-5330
Practice Address - Street 1:507 AIRPORT EXECUTIVE PARK
Practice Address - Street 2:
Practice Address - City:NANUET
Practice Address - State:NY
Practice Address - Zip Code:10954-5238
Practice Address - Country:US
Practice Address - Phone:845-262-5313
Practice Address - Fax:845-262-5330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-05
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty