Provider Demographics
NPI:1376914580
Name:PROGRESSIVE SPINE & SPORTS MEDICINE
Entity Type:Organization
Organization Name:PROGRESSIVE SPINE & SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MCELROY
Authorized Official - Suffix:
Authorized Official - Credentials:DO,
Authorized Official - Phone:201-962-9199
Mailing Address - Street 1:48 S FRANKLIN TPKE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:RAMSEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07446-2558
Mailing Address - Country:US
Mailing Address - Phone:201-962-9199
Mailing Address - Fax:201-962-9198
Practice Address - Street 1:48 S FRANKLIN TPKE
Practice Address - Street 2:SUITE 101
Practice Address - City:RAMSEY
Practice Address - State:NJ
Practice Address - Zip Code:07446-2558
Practice Address - Country:US
Practice Address - Phone:201-962-9199
Practice Address - Fax:201-962-9198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-14
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB08770900305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ377196Medicare UPIN