Provider Demographics
NPI:1700336468
Name:SOUTH JERSEY SPORTS MEDICINE CENTER PC
Entity Type:Organization
Organization Name:SOUTH JERSEY SPORTS MEDICINE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:FALCONIERO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:609-703-5097
Mailing Address - Street 1:556 EGG HARBOR RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-2326
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:556 EGG HARBOR RD
Practice Address - Street 2:SUITE A
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-2326
Practice Address - Country:US
Practice Address - Phone:856-589-0650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-06
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB04705300332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site