Provider Demographics
NPI:1619938727
Name:PROFESSIONAL SPORTS CARE MANAGEMENT INC
Entity Type:Organization
Organization Name:PROFESSIONAL SPORTS CARE MANAGEMENT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TARVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-975-4503
Mailing Address - Street 1:1 BRANCA RD
Mailing Address - Street 2:
Mailing Address - City:EAST RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07073-2121
Mailing Address - Country:US
Mailing Address - Phone:201-933-1112
Mailing Address - Fax:
Practice Address - Street 1:1 BRANCA RD
Practice Address - Street 2:
Practice Address - City:EAST RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07073-2121
Practice Address - Country:US
Practice Address - Phone:201-933-1112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ316594Medicare ID - Type UnspecifiedPROVIDER NUMBER