Provider Demographics
NPI:1720528409
Name:ORTHOPAEDIC, SPORTS MEDICINE AND REHABILITATION CENTER, PA
Entity Type:Organization
Organization Name:ORTHOPAEDIC, SPORTS MEDICINE AND REHABILITATION CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LISSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-703-5097
Mailing Address - Street 1:25 KILMER DR
Mailing Address - Street 2:BUILDING 3 SUITE 104
Mailing Address - City:MORGANVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07751-1564
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 KILMER DR
Practice Address - Street 2:BUILDING 3 SUITE 104
Practice Address - City:MORGANVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07751-1564
Practice Address - Country:US
Practice Address - Phone:732-617-9111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08297500332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site