Provider Demographics
NPI:1679637052
Name:ORTHOPAEDIC AND SPORTS MEDICINE SPECIALISTS, INC
Entity Type:Organization
Organization Name:ORTHOPAEDIC AND SPORTS MEDICINE SPECIALISTS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-888-2100
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:HOLMDEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07733
Mailing Address - Country:US
Mailing Address - Phone:732-888-2100
Mailing Address - Fax:732-888-2188
Practice Address - Street 1:719 NORTH BEERS ST
Practice Address - Street 2:SUITE C-1
Practice Address - City:HOLMDEL
Practice Address - State:NJ
Practice Address - Zip Code:07733
Practice Address - Country:US
Practice Address - Phone:732-888-2100
Practice Address - Fax:732-888-2188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07887100207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0082295Medicaid
NJI10942Medicare UPIN
NJ101714Medicare ID - Type UnspecifiedGROUP MDCR #