Provider Demographics
NPI:1659326569
Name:ACTIVE ORTHOPAEDICS AND SPORTS MEDICINE, PA
Entity Type:Organization
Organization Name:ACTIVE ORTHOPAEDICS AND SPORTS MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-358-0707
Mailing Address - Street 1:390 OLD HOOK RD
Mailing Address - Street 2:
Mailing Address - City:WESTWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-2616
Mailing Address - Country:US
Mailing Address - Phone:201-358-0707
Mailing Address - Fax:201-358-9777
Practice Address - Street 1:25 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1960
Practice Address - Country:US
Practice Address - Phone:201-343-2277
Practice Address - Fax:201-343-7410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA5362900207XX0005X
NJ25MA08256500207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJCK8050OtherRAILROAD MEDICARE
NJCK8050OtherRAILROAD MEDICARE
NJ078718Medicare ID - Type UnspecifiedNJ GROUP