Provider Demographics
NPI:1316997331
Name:SOUTH JERSEY SPORTS MEDICINE CENTER PC
Entity type:Organization
Organization Name:SOUTH JERSEY SPORTS MEDICINE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:VERSAGGI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-589-0650
Mailing Address - Street 1:556 EGG HARBOR RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-2326
Mailing Address - Country:US
Mailing Address - Phone:856-589-0650
Mailing Address - Fax:856-589-2720
Practice Address - Street 1:556 EGG HARBOR RD
Practice Address - Street 2:SUITE A
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-2326
Practice Address - Country:US
Practice Address - Phone:856-589-0650
Practice Address - Fax:856-589-2720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ579835Medicare PIN
PA061910Medicare PIN