Provider Demographics
NPI:1538516950
Name:PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY OF NJ, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY OF NJ, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-819-6805
Mailing Address - Street 1:576 BROADHOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-5002
Mailing Address - Country:US
Mailing Address - Phone:631-359-5859
Mailing Address - Fax:631-396-0865
Practice Address - Street 1:112 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006-5336
Practice Address - Country:US
Practice Address - Phone:973-226-2434
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-16
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ255015Medicare PIN