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?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty