Provider Demographics
NPI:1720192891
Name:AMERICAN ORTHOPEDIC AND SPORTS MEDICINE PA
Entity Type:Organization
Organization Name:AMERICAN ORTHOPEDIC AND SPORTS MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOANN
Authorized Official - Middle Name:C
Authorized Official - Last Name:DEROSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-986-1003
Mailing Address - Street 1:30 W CENTURY RD
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-1433
Mailing Address - Country:US
Mailing Address - Phone:201-986-1003
Mailing Address - Fax:201-986-1680
Practice Address - Street 1:30 W CENTURY RD
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-1433
Practice Address - Country:US
Practice Address - Phone:201-986-1003
Practice Address - Fax:201-986-1680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04269600204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC54180Medicare UPIN
NJ065545Medicare ID - Type UnspecifiedMEDICARE