Provider Demographics
NPI:1427302512
Name:INTEGRATIVE SPINE & ORTHOPEDIC REHABILITATION
Entity type:Organization
Organization Name:INTEGRATIVE SPINE & ORTHOPEDIC REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-746-2424
Mailing Address - Street 1:1 GREENWOOD AVE
Mailing Address - Street 2:SUITE #100
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-3649
Mailing Address - Country:US
Mailing Address - Phone:973-746-2424
Mailing Address - Fax:973-746-5030
Practice Address - Street 1:1 GREENWOOD AVE
Practice Address - Street 2:SUITE #100
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-3649
Practice Address - Country:US
Practice Address - Phone:973-746-2424
Practice Address - Fax:973-746-5030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA070292002081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty