Provider Demographics
NPI:1811062656
Name:ACTIVE ORTHOPAEDICS & SPORTS MEDICINE, PLLC
Entity type:Organization
Organization Name:ACTIVE ORTHOPAEDICS & SPORTS MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:HARDING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-694-0000
Mailing Address - Street 1:340 BROADHOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-4807
Mailing Address - Country:US
Mailing Address - Phone:631-694-0000
Mailing Address - Fax:
Practice Address - Street 1:340 BROADHOLLOW RD
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-4807
Practice Address - Country:US
Practice Address - Phone:631-694-0000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WWT461OtherGROUP
NY86G741Medicare PIN