Provider Demographics
NPI: | 1689816860 |
---|---|
Name: | PERFORMANCE SPINE & SPORTS MEDICINE |
Entity Type: | Organization |
Organization Name: | PERFORMANCE SPINE & SPORTS MEDICINE |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | MATTHIAS |
Authorized Official - Middle Name: | H |
Authorized Official - Last Name: | WIEDERHOLZ |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 609-588-8600 |
Mailing Address - Street 1: | PO BOX 649842 |
Mailing Address - Street 2: | |
Mailing Address - City: | DALLAS |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 75264-9842 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 609-588-8600 |
Mailing Address - Fax: | 609-588-8602 |
Practice Address - Street 1: | 4056 QUAKERBRIDGE RD STE 112 |
Practice Address - Street 2: | |
Practice Address - City: | LAWRENCEVILLE |
Practice Address - State: | NJ |
Practice Address - Zip Code: | 08648-4779 |
Practice Address - Country: | US |
Practice Address - Phone: | 609-588-8600 |
Practice Address - Fax: | 609-588-8602 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2009-04-02 |
Last Update Date: | 2024-04-25 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208VP0014X | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | Group - Multi-Specialty |