Provider Demographics
NPI:1326282088
Name:PERFORMANCE ORTHOPAEDICS & SPORTS MEDICINE, LLC
Entity Type:Organization
Organization Name:PERFORMANCE ORTHOPAEDICS & SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-567-7350
Mailing Address - Street 1:780 ROUTE 37 W STE 330
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08755-5064
Mailing Address - Country:US
Mailing Address - Phone:732-691-4898
Mailing Address - Fax:732-608-8950
Practice Address - Street 1:780 ROUTE 37 W STE 330
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-5064
Practice Address - Country:US
Practice Address - Phone:732-691-4898
Practice Address - Fax:732-608-8950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-26
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07911500207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1396932091Medicare UPIN