Provider Demographics
NPI:1720403587
Name:NORTHEAST ORTHOPEDICS AND SPORTS MEDICINE PLLC
Entity Type:Organization
Organization Name:NORTHEAST ORTHOPEDICS AND SPORTS MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-359-1877
Mailing Address - Street 1:8 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:NY
Mailing Address - Zip Code:10970-3516
Mailing Address - Country:US
Mailing Address - Phone:845-359-1877
Mailing Address - Fax:845-359-1877
Practice Address - Street 1:8 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:NY
Practice Address - Zip Code:10970-3516
Practice Address - Country:US
Practice Address - Phone:845-359-1877
Practice Address - Fax:845-359-1877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-03
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies