Provider Demographics
NPI:1245565563
Name:SUBURBAN SPINE AND ORTHOPEDIC CENTER, LLC
Entity Type:Organization
Organization Name:SUBURBAN SPINE AND ORTHOPEDIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:FOTI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:610-558-1001
Mailing Address - Street 1:931 E HAVERFORD RD STE 202
Mailing Address - Street 2:
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-3838
Mailing Address - Country:US
Mailing Address - Phone:610-558-1001
Mailing Address - Fax:610-558-1180
Practice Address - Street 1:931 E HAVERFORD RD STE 202
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3838
Practice Address - Country:US
Practice Address - Phone:610-558-1001
Practice Address - Fax:610-558-1180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-05
Last Update Date:2018-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS 009073L207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty