Provider Demographics
NPI:1609272095
Name:RECONSTRUCTIVE ORTHOPEDICS, P.A.
Entity Type:Organization
Organization Name:RECONSTRUCTIVE ORTHOPEDICS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:MICKLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-267-9400
Mailing Address - Street 1:4 EVES DR # A
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3195
Mailing Address - Country:US
Mailing Address - Phone:609-267-9400
Mailing Address - Fax:
Practice Address - Street 1:401 YOUNG AVE
Practice Address - Street 2:SUITE 245
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-3130
Practice Address - Country:US
Practice Address - Phone:609-267-9400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RECONSTRUCTIVE ORTHOPEDICS, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-12
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty