Basic Information
| Provider Information | |||||||||
| NPI: | 1427302512 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATIVE SPINE & ORTHOPEDIC REHABILITATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 GREENWOOD AVE | ||||||||
| Address2: | SUITE #100 | ||||||||
| City: | MONTCLAIR | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070423649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737462424 | ||||||||
| FaxNumber: | 9737465030 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 GREENWOOD AVE | ||||||||
| Address2: | SUITE #100 | ||||||||
| City: | MONTCLAIR | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070423649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737462424 | ||||||||
| FaxNumber: | 9737465030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2012 | ||||||||
| LastUpdateDate: | 10/29/2012 | ||||||||
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| AuthorizedOfficialLastName: | CARTER | ||||||||
| AuthorizedOfficialFirstName: | ALICIA | ||||||||
| AuthorizedOfficialMiddleName: | RUSSELL | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9737462424 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | 25MA07029200 | NJ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
No ID Information.