Provider Demographics
NPI:1932197563
Name:TEMPLE UNIVERSITY OF THE COMMONWEALTH SYSTEM OF HIGHER EDUCATION
Entity Type:Organization
Organization Name:TEMPLE UNIVERSITY OF THE COMMONWEALTH SYSTEM OF HIGHER EDUCATION
Other - Org Name:NJ SPORTS MEDICINE TEMPLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, GOVERNMENT AND PAYER RELA
Authorized Official - Prefix:MS
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-596-0906
Mailing Address - Street 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:856-596-0609
Mailing Address - Fax:856-596-6918
Practice Address - Street 1:ROUTE 73 N
Practice Address - Street 2:ONE GREENTREE CENTER
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053
Practice Address - Country:US
Practice Address - Phone:856-596-0906
Practice Address - Fax:856-596-6918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-07
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6202403Medicaid
NJ404666Medicare ID - Type Unspecified