Provider Demographics
NPI:1710151014
Name:CENTRAL JERSEY SPORTS MEDICINE & ORTHOPAEDIC CENTER
Entity Type:Organization
Organization Name:CENTRAL JERSEY SPORTS MEDICINE & ORTHOPAEDIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-905-8153
Mailing Address - Street 1:101 PROSPECT ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5020
Mailing Address - Country:US
Mailing Address - Phone:732-905-8153
Mailing Address - Fax:
Practice Address - Street 1:101 PROSPECT ST
Practice Address - Street 2:SUITE 107
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5020
Practice Address - Country:US
Practice Address - Phone:732-905-8153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06286400207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ200025845OtherRAILROAD MEDICARE
NJ0101389Medicaid
NJ6009584OtherGHI
NJ0101389Medicaid
NJ200025845OtherRAILROAD MEDICARE