Basic Information
Provider Information | |||||||||
NPI: | 1023415866 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RECONSTRUCTIVE ORTHOPEDICS, P.A. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
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Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
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OtherLastName: |   | ||||||||
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Mailing Information | |||||||||
Address1: | 4 EVES DR # A | ||||||||
Address2: | SUITE 100 | ||||||||
City: | MARLTON | ||||||||
State: | NJ | ||||||||
PostalCode: | 080533195 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6092679400 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 239 HURFFVILLE CROSSKEYS RD | ||||||||
Address2: | SUITE 440 | ||||||||
City: | SEWELL | ||||||||
State: | NJ | ||||||||
PostalCode: | 080804002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8566292688 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/21/2014 | ||||||||
LastUpdateDate: | 11/21/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MICKLE | ||||||||
AuthorizedOfficialFirstName: | AMY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 6092679400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | RECONSTRUCTIVE ORTHOPEDICS, P.A. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
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NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 2081P2900X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 363A00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363AS0400X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 207X00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
No ID Information.