1215248299 NPI number — MAM ORTHOPAEDICS, PA

Table of content: (NPI 1215248299)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215248299 NPI number — MAM ORTHOPAEDICS, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAM ORTHOPAEDICS, PA
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:
SPORTS MEDICINE AND ORTHOPAEDIC CENTER OF NEW JERSEY
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:
1215248299
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 ELM AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HACKENSACK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07601-4702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-968-0508
Provider Business Mailing Address Fax Number:
201-968-0509

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17 ELM AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HACKENSACK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07601-4702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-968-0508
Provider Business Practice Location Address Fax Number:
201-968-0509
Provider Enumeration Date:
06/24/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MEESE
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
MEDICAL DOCTOR
Authorized Official Telephone Number:
201-968-0508

Provider Taxonomy Codes

  • Taxonomy code: 163WX0800X , with the licence number:  255MA05232100 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0005X , with the licence number: 25MA05232100 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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