Provider Demographics
NPI:1699228650
Name:PERFORMANCE SPINE AND SPORTS MEDICINE EAST BRUNSWICK
Entity Type:Organization
Organization Name:PERFORMANCE SPINE AND SPORTS MEDICINE EAST BRUNSWICK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:SALERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-817-0052
Mailing Address - Street 1:555 STATE ROUTE 18
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-3713
Mailing Address - Country:US
Mailing Address - Phone:609-817-0052
Mailing Address - Fax:
Practice Address - Street 1:555 STATE ROUTE 18
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-3713
Practice Address - Country:US
Practice Address - Phone:609-817-0052
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-26
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09258600174400000X
NJ25MA08922900174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ000000OtherMULTI-SPECIALTY