Provider Demographics
NPI:1215443841
Name:NORTH JERSEY SPORTS MEDICINE & ORTHOPEDIC CENTER, LLC
Entity type:Organization
Organization Name:NORTH JERSEY SPORTS MEDICINE & ORTHOPEDIC CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEFALCO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:908-684-3005
Mailing Address - Street 1:108 BILBY RD STE 201
Mailing Address - Street 2:
Mailing Address - City:HACKETTSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07840-4174
Mailing Address - Country:US
Mailing Address - Phone:908-684-3005
Mailing Address - Fax:908-684-3301
Practice Address - Street 1:218 RIDGEDALE AVE STE 202
Practice Address - Street 2:
Practice Address - City:CEDAR KNOLLS
Practice Address - State:NJ
Practice Address - Zip Code:07927-2109
Practice Address - Country:US
Practice Address - Phone:908-684-3005
Practice Address - Fax:908-684-3301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-19
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB069711207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty