Provider Demographics
NPI:1013342609
Name:NORTH JERSEY SPORTS MEDICINE & ORTHOPEDIC CENTER, LLC
Entity type:Organization
Organization Name:NORTH JERSEY SPORTS MEDICINE & ORTHOPEDIC CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEFALCO
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:908-684-3005
Mailing Address - Street 1:108 BILBY ROAD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:HACKETTSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07840
Mailing Address - Country:US
Mailing Address - Phone:908-684-3005
Mailing Address - Fax:908-684-3301
Practice Address - Street 1:66 SUNSET STRIP
Practice Address - Street 2:SUITE 400
Practice Address - City:SUCCASUNNA
Practice Address - State:NJ
Practice Address - Zip Code:07876
Practice Address - Country:US
Practice Address - Phone:908-684-3005
Practice Address - Fax:908-684-3301
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH JERSEY SPORTS MEDICINE & ORTHOPEDIC C
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-09-13
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB06992500174400000X
NJ25MB06971100174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5725900001Medicare NSC
NJ100250Medicare PIN