Provider Demographics
NPI:1417123621
Name:NEW JERSEY INSTITUTE FOR MINIMALLY INVASIVE SPINE CARE, PA
Entity Type:Organization
Organization Name:NEW JERSEY INSTITUTE FOR MINIMALLY INVASIVE SPINE CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SRI
Authorized Official - Middle Name:
Authorized Official - Last Name:KANTHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-736-7300
Mailing Address - Street 1:300 MAIN ST
Mailing Address - Street 2:21 MADISON PLAZA #107
Mailing Address - City:MADISON
Mailing Address - State:NJ
Mailing Address - Zip Code:07940-2369
Mailing Address - Country:US
Mailing Address - Phone:973-736-7300
Mailing Address - Fax:973-736-7322
Practice Address - Street 1:345 MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-5700
Practice Address - Country:US
Practice Address - Phone:973-736-7300
Practice Address - Fax:973-736-7322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMAO40008174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC61115Medicare UPIN
NJ804307Medicare PIN