Basic Information
| Provider Information | |||||||||
| NPI: | 1205316528 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROFESSIONAL ORTHOPEDIC AND SPORTS THERAPY OF NJ, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 576 BROADHOLLOW RD | ||||||||
| Address2: | |||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117475002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313595859 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2200 FLETCHER AVE STE 505 | ||||||||
| Address2: | |||||||||
| City: | FORT LEE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018495201 | ||||||||
| FaxNumber: | 2018495014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2018 | ||||||||
| LastUpdateDate: | 08/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | BRUSH | ||||||||
| AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6313595805 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY, P.C. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.