Provider Demographics
NPI:1922435395
Name:ADVANTAGE SPORTS MEDICINE LLC
Entity Type:Organization
Organization Name:ADVANTAGE SPORTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:S
Authorized Official - Last Name:BOTTIGLIERI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:201-569-0010
Mailing Address - Street 1:PO BOX 70176
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10307-0176
Mailing Address - Country:US
Mailing Address - Phone:718-984-4094
Mailing Address - Fax:
Practice Address - Street 1:67 BROADWAY
Practice Address - Street 2:
Practice Address - City:ELMWOOD PARK
Practice Address - State:NJ
Practice Address - Zip Code:07407-1836
Practice Address - Country:US
Practice Address - Phone:201-569-0010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-01
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25 MB07982100261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty