Provider Demographics
NPI:1093095937
Name:JERSEY SPINE ASSOCIATES LLC
Entity Type:Organization
Organization Name:JERSEY SPINE ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHOPAEDIC SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:RAVI
Authorized Official - Middle Name:KUMAR
Authorized Official - Last Name:PONNAPPAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-601-4920
Mailing Address - Street 1:750 ROUTE 73 SOUTH
Mailing Address - Street 2:SUITE 301
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-5343
Mailing Address - Country:US
Mailing Address - Phone:609-601-4920
Mailing Address - Fax:609-601-4921
Practice Address - Street 1:750 ROUTE 73 SOUTH
Practice Address - Street 2:SUITE 301
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-5343
Practice Address - Country:US
Practice Address - Phone:609-601-4920
Practice Address - Fax:609-601-4921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-24
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08240900207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP00452796Medicare PIN
NJ113355PFCMedicare PIN