Provider Demographics
NPI:1104161884
Name:PERFORMANCE SPINE AND SPORTS MEDICINE OF NEWTOWN, LLC
Entity type:Organization
Organization Name:PERFORMANCE SPINE AND SPORTS MEDICINE OF NEWTOWN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHIAS
Authorized Official - Middle Name:HEINZ
Authorized Official - Last Name:WIEDERHOLZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-504-2223
Mailing Address - Street 1:828A NEWTOWN YARDLEY RD
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18940-4012
Mailing Address - Country:US
Mailing Address - Phone:215-504-2223
Mailing Address - Fax:215-504-2141
Practice Address - Street 1:828A NEWTOWN YARDLEY RD
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:PA
Practice Address - Zip Code:18940-4012
Practice Address - Country:US
Practice Address - Phone:215-504-2223
Practice Address - Fax:215-504-2141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-06
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD440879332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies