Provider Demographics
NPI:1154030328
Name:ORTHOPAEDICS SPINE AND SPORTS MEDICINE LLC
Entity type:Organization
Organization Name:ORTHOPAEDICS SPINE AND SPORTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:TASSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-795-3033
Mailing Address - Street 1:12 UNQUA RD
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-6727
Mailing Address - Country:US
Mailing Address - Phone:516-795-3033
Mailing Address - Fax:516-654-9358
Practice Address - Street 1:16 E 29TH ST FL 2
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-4603
Practice Address - Country:US
Practice Address - Phone:201-971-7070
Practice Address - Fax:201-339-2109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-16
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty