Basic Information
| Provider Information | |||||||||
| NPI: | 1790923480 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEW JERSEY SPORTS MEDICINE LLC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 197 RIDGEDALE AVE. | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | CEDAR KNOLLS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739988301 | ||||||||
| FaxNumber: | 9739988302 | ||||||||
| Practice Location | |||||||||
| Address1: | 197 RIDGEDALE AVE | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | CEDAR KNOLLS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739988301 | ||||||||
| FaxNumber: | 9739988302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2009 | ||||||||
| LastUpdateDate: | 04/24/2013 | ||||||||
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| AuthorizedOfficialLastName: | BOWEN | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 9739988301 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.