Provider Demographics
NPI:1649469081
Name:SPINE ORTHOPEDIC AND SPORTS MEDICINE
Entity type:Organization
Organization Name:SPINE ORTHOPEDIC AND SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MIRZA
Authorized Official - Middle Name:
Authorized Official - Last Name:BEG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-470-8848
Mailing Address - Street 1:1084 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07011-2330
Mailing Address - Country:US
Mailing Address - Phone:973-470-8848
Mailing Address - Fax:973-470-8826
Practice Address - Street 1:1084 MAIN AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-2330
Practice Address - Country:US
Practice Address - Phone:973-470-8848
Practice Address - Fax:973-470-8826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06785400174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty