Provider Demographics
NPI:1083773857
Name:NJ SPINE GROUP, LLC
Entity Type:Organization
Organization Name:NJ SPINE GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:D
Authorized Official - Last Name:DONALD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-747-7110
Mailing Address - Street 1:234 INDUSTRIAL WAY W
Mailing Address - Street 2:STE A200
Mailing Address - City:EATONTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07724-4244
Mailing Address - Country:US
Mailing Address - Phone:732-747-7110
Mailing Address - Fax:732-747-7664
Practice Address - Street 1:234 INDUSTRIAL WAY W
Practice Address - Street 2:STE A200
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-4244
Practice Address - Country:US
Practice Address - Phone:732-747-7110
Practice Address - Fax:732-747-7664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-07
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA46751207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ077472Medicare UPIN