Basic Information
| Provider Information | |||||||||
| NPI: | 1376951889 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY OF NJ, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 576 BROADHOLLOW RD | ||||||||
| Address2: | |||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117475002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163212400 | ||||||||
| FaxNumber: | 5163212401 | ||||||||
| Practice Location | |||||||||
| Address1: | 440 OLD HOOK RD | ||||||||
| Address2: | |||||||||
| City: | EMERSON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076302302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2014976752 | ||||||||
| FaxNumber: | 2014976756 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2014 | ||||||||
| LastUpdateDate: | 03/28/2018 | ||||||||
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| AuthorizedOfficialLastName: | BRUSH | ||||||||
| AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7188196805 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROFESSIONAL ORTHOPEDIC AND SPORTS PHYSICAL THERAPY, P.C. | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 255015 | 01 | NJ | MEDICARE GROUP PTAN | OTHER |