Provider Demographics
NPI:1972710036
Name:PERTH AMBOY PHYSICAL THERAPY & SPORTS MEDICINE CENTER
Entity Type:Organization
Organization Name:PERTH AMBOY PHYSICAL THERAPY & SPORTS MEDICINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DERON
Authorized Official - Middle Name:J
Authorized Official - Last Name:RAMOS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:732-324-7800
Mailing Address - Street 1:600 STATE ST.
Mailing Address - Street 2:
Mailing Address - City:PERTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08861
Mailing Address - Country:US
Mailing Address - Phone:732-324-7800
Mailing Address - Fax:732-324-7825
Practice Address - Street 1:600 STATE ST.
Practice Address - Street 2:
Practice Address - City:PERTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08861
Practice Address - Country:US
Practice Address - Phone:732-324-7800
Practice Address - Fax:732-324-7825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00501000261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2880Medicare ID - Type Unspecified