Provider Demographics
NPI:1528132289
Name:GARDEN STATE ORTHOPAEDICS AND SPORTS MEDICINE
Entity type:Organization
Organization Name:GARDEN STATE ORTHOPAEDICS AND SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:LESLIE
Authorized Official - Last Name:KAHN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-616-2999
Mailing Address - Street 1:455 ROUTE 70 WEST
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08002
Mailing Address - Country:US
Mailing Address - Phone:856-616-2999
Mailing Address - Fax:856-616-1437
Practice Address - Street 1:455 ROUTE 70 WEST
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002
Practice Address - Country:US
Practice Address - Phone:856-616-2999
Practice Address - Fax:856-616-1437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5646804Medicaid
CJ9376OtherRR MEDICARE
D87253OtherBLAIR MILL AMERIHEALTH
GA524920BE8Medicare ID - Type Unspecified