Provider Demographics
NPI:1215261037
Name:NORTH JERSEY ORTHOPAEDIC & SPORTS MEDICINE INSTITUTE
Entity type:Organization
Organization Name:NORTH JERSEY ORTHOPAEDIC & SPORTS MEDICINE INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:RUSSONELLA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:973-340-1940
Mailing Address - Street 1:6 BRIGHTON RD STE 101
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07012-1647
Mailing Address - Country:US
Mailing Address - Phone:973-340-1940
Mailing Address - Fax:973-340-1958
Practice Address - Street 1:6 BRIGHTON RD STE 101
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07012-1647
Practice Address - Country:US
Practice Address - Phone:973-340-1940
Practice Address - Fax:973-340-1958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-25
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB08615500207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty