Provider Demographics
NPI:1639507684
Name:GARDEN STATE ORTHOCARE LLC
Entity Type:Organization
Organization Name:GARDEN STATE ORTHOCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:EHRLICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:888-721-6238
Mailing Address - Street 1:68 BOULDER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SCARSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10583-3150
Mailing Address - Country:US
Mailing Address - Phone:917-886-5545
Mailing Address - Fax:718-795-9003
Practice Address - Street 1:321 ESSEX ST
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-2066
Practice Address - Country:US
Practice Address - Phone:888-721-6238
Practice Address - Fax:888-721-6238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09089400207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty