Provider Demographics
NPI:1508014242
Name:PODIATRIC WELLNESS SPORTS MEDICINE CENTER INC
Entity Type:Organization
Organization Name:PODIATRIC WELLNESS SPORTS MEDICINE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:DELLEGROTTI
Authorized Official - Suffix:SR
Authorized Official - Credentials:DPM
Authorized Official - Phone:609-758-8008
Mailing Address - Street 1:10 MAIN ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:NEW EGYPT
Mailing Address - State:NJ
Mailing Address - Zip Code:08533-1400
Mailing Address - Country:US
Mailing Address - Phone:609-758-8008
Mailing Address - Fax:
Practice Address - Street 1:10 MAIN ST
Practice Address - Street 2:SUITE E
Practice Address - City:NEW EGYPT
Practice Address - State:NJ
Practice Address - Zip Code:08533-1400
Practice Address - Country:US
Practice Address - Phone:609-758-8008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-07
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00263400261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
04991Medicare PIN
U86287Medicare UPIN
NJ6438180001Medicare NSC