Basic Information
| Provider Information | |||||||||
| NPI: | 1710117437 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RUTGERS, THE STATE UNIVERSITY OF NEW JERSEY | ||||||||
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| OtherOrganizationName: | RUTGERS UNIVERSITY SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 168007 | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750168007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668906390 | ||||||||
| FaxNumber: | 3254378390 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 SCARLET KNIGHT WAY | ||||||||
| Address2: | |||||||||
| City: | PISCATAWAY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088548069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7324456258 | ||||||||
| FaxNumber: | 7324452780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2009 | ||||||||
| LastUpdateDate: | 07/15/2009 | ||||||||
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| AuthorizedOfficialLastName: | JEITNER | ||||||||
| AuthorizedOfficialFirstName: | MELANIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ATHLETIC INSURANCE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7324456258 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.