Provider Demographics
NPI:1578848651
Name:PERFORMANCE SPINE AND SPORTS MEDICINE OF NEWTOWN, LLC
Entity Type:Organization
Organization Name:PERFORMANCE SPINE AND SPORTS MEDICINE OF NEWTOWN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MAREK
Authorized Official - Middle Name:
Authorized Official - Last Name:SULZYNSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-588-8600
Mailing Address - Street 1:828 NEWTOWN YARDLEY ROAD
Mailing Address - Street 2:A
Mailing Address - City:NEWTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18940
Mailing Address - Country:US
Mailing Address - Phone:609-588-8600
Mailing Address - Fax:609-588-8602
Practice Address - Street 1:828 NEWTOWN YARDLEY ROAD
Practice Address - Street 2:A
Practice Address - City:NEWTOWN
Practice Address - State:PA
Practice Address - Zip Code:18940
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:2011-10-20
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4335292081P2900X
NJ25MA087259002081P2900X
NJ40QA01357000225100000X
PAMD019816225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA=========OtherEIN # ...THIS IS A NEW COMPANY