Provider Demographics
NPI:1306350830
Name:ELITE SPORTS MEDICINE AND WELLNESS LLC
Entity type:Organization
Organization Name:ELITE SPORTS MEDICINE AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAI
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOSHANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-431-5115
Mailing Address - Street 1:46 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:CRESSKILL
Mailing Address - State:NJ
Mailing Address - Zip Code:07626-2125
Mailing Address - Country:US
Mailing Address - Phone:201-431-5115
Mailing Address - Fax:201-399-7697
Practice Address - Street 1:46 UNION AVE
Practice Address - Street 2:
Practice Address - City:CRESSKILL
Practice Address - State:NJ
Practice Address - Zip Code:07626-2125
Practice Address - Country:US
Practice Address - Phone:201-431-5115
Practice Address - Fax:201-399-7697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-20
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09267900207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty