Provider Demographics
NPI:1659319002
Name:RECONSTRUCTIVE ORTHOPEDICS, PA
Entity Type:Organization
Organization Name:RECONSTRUCTIVE ORTHOPEDICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MRS
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 1:4 EVES DR # A
Practice Address - Street 2:SUITE 100
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-3195
Practice Address - Country:US
Practice Address - Phone:609-267-9400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207X00000X, 2081P2900X, 363A00000X
NJ207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ35052OtherAETNA ID NUMBER
NJRE137317Medicare ID - Type Unspecified
NJ6330270001Medicare NSC