Provider Demographics
NPI:1588686604
Name:SOUTH JERSEY SPORTS & SPINE MEDICINE LLC
Entity type:Organization
Organization Name:SOUTH JERSEY SPORTS & SPINE MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MERYL
Authorized Official - Middle Name:Y
Authorized Official - Last Name:STEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-874-9777
Mailing Address - Street 1:PO BOX 22462
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19110-2462
Mailing Address - Country:US
Mailing Address - Phone:215-732-7600
Mailing Address - Fax:856-874-9444
Practice Address - Street 1:525 ROUTE 73 SOUTH
Practice Address - Street 2:EVESHAM COMMONS- SUITE 104A
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-9643
Practice Address - Country:US
Practice Address - Phone:856-874-9777
Practice Address - Fax:856-874-9444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2625614000OtherAMERIHEALTH
NJ610782200OtherDEPARTMENT OF LABOR
NJ0075728Medicaid
NJ2625614000OtherAMERIHEALTH