1194904730 NPI number — EAST COAST SPINE JOINT AND SPORTS MEDICINE

Table of content: (NPI 1194904730)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194904730 NPI number — EAST COAST SPINE JOINT AND SPORTS MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST COAST SPINE JOINT AND SPORTS MEDICINE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THE SPINE AND SPORTS HEALTH CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194904730
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
720 MONROE STREET
Provider Second Line Business Mailing Address:
SUITE C-208
Provider Business Mailing Address City Name:
HOBOKEN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07030-5000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-533-9200
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
720 MONROE STREET
Provider Second Line Business Practice Location Address:
SUITE C-208
Provider Business Practice Location Address City Name:
HOBOKEN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07030-5000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-533-9200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VISCO
Authorized Official First Name:
ALEXANDER
Authorized Official Middle Name:
J
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
201-533-9200

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  38MC00542700 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X , with the licence number: 25MA07808900 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2081S0010X , with the licence number: 25MA07808900 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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