Provider Demographics
NPI:1689878126
Name:ATLANTIC BRAIN & SPINE LLC
Entity Type:Organization
Organization Name:ATLANTIC BRAIN & SPINE LLC
Other - Org Name:ATLANTIC BRAIN & SPINE INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:HODOSH
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACS
Authorized Official - Phone:908-522-4979
Mailing Address - Street 1:99 BEAUVOIR AVE
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901-3533
Mailing Address - Country:US
Mailing Address - Phone:908-522-4979
Mailing Address - Fax:908-522-5377
Practice Address - Street 1:99 BEAUVOIR AVE
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-3533
Practice Address - Country:US
Practice Address - Phone:908-522-4979
Practice Address - Fax:908-522-5377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA037407207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0182109Medicaid
NJD98856Medicare UPIN