Provider Demographics
NPI:1528155561
Name:ADVANCED SPORTS MEDICINE AND PT
Entity type:Organization
Organization Name:ADVANCED SPORTS MEDICINE AND PT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:CARMEAN
Authorized Official - Last Name:FOSS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:973-616-4555
Mailing Address - Street 1:18 NEWARK POMPTON TPKE
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07457
Mailing Address - Country:US
Mailing Address - Phone:973-616-4555
Mailing Address - Fax:973-616-3430
Practice Address - Street 1:18 NEWARK POMPTON TPKE
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:NJ
Practice Address - Zip Code:07457
Practice Address - Country:US
Practice Address - Phone:973-616-4555
Practice Address - Fax:973-616-3430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01152400225100000X
NJ38MC00465700111N00000X
NJ38MC00465800111N00000X
NJ46TR00647900225X00000X
NJ1285678045207R00000X
NJ40QA01130300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ043572Medicare PIN