Provider Demographics
NPI:1275924904
Name:NORTH JERSEY ORTHOPEDIC SPORTS TRAUMA INSTITUTE E LLC
Entity Type:Organization
Organization Name:NORTH JERSEY ORTHOPEDIC SPORTS TRAUMA INSTITUTE E LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENBLUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-794-6008
Mailing Address - Street 1:15-01 BROADWAY STE 20
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-6003
Mailing Address - Country:US
Mailing Address - Phone:847-275-3633
Mailing Address - Fax:
Practice Address - Street 1:15-01 BROADWAY STE 20
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-6003
Practice Address - Country:US
Practice Address - Phone:847-275-3633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-17
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05165000207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1C528813BMMMedicare UPIN