Provider Demographics
NPI:1598712556
Name:ORTHOPEDIC SURGERY & SPORTS MEDICINE CENTER, LLC
Entity Type:Organization
Organization Name:ORTHOPEDIC SURGERY & SPORTS MEDICINE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-616-0200
Mailing Address - Street 1:61 BEAVERBROOK RD
Mailing Address - Street 2:STE 201
Mailing Address - City:LINCOLN PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07035-1748
Mailing Address - Country:US
Mailing Address - Phone:973-616-0200
Mailing Address - Fax:973-696-9294
Practice Address - Street 1:61 BEAVERBROOK RD
Practice Address - Street 2:STE 201
Practice Address - City:LINCOLN PARK
Practice Address - State:NJ
Practice Address - Zip Code:07035-1748
Practice Address - Country:US
Practice Address - Phone:973-616-0200
Practice Address - Fax:973-696-9294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ43990174400000X
NJ62817174400000X
NJ64376174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5896220002Medicare NSC
NJ071207Medicare PIN