Provider Demographics
NPI:1437587193
Name:PERFORMANCE SPINE AND SPORTS MEDICINE OF BORDENTOWN, LLC
Entity Type:Organization
Organization Name:PERFORMANCE SPINE AND SPORTS MEDICINE OF BORDENTOWN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:DELELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-588-8600
Mailing Address - Street 1:9500 K. JOHNSON BLVD
Mailing Address - Street 2:
Mailing Address - City:BORDENTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08505-4400
Mailing Address - Country:US
Mailing Address - Phone:609-588-8600
Mailing Address - Fax:609-588-8602
Practice Address - Street 1:9500 K. JOHNSON BLVD
Practice Address - Street 2:
Practice Address - City:BORDENTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08505-4400
Practice Address - Country:US
Practice Address - Phone:609-588-8600
Practice Address - Fax:609-588-8602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-16
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2081S0010XOtherPHYSICAL MEDICINE & REHABILITATION/MULT-SPECIALTY GROUP