Provider Demographics
NPI:1962772483
Name:NORTH JERSEY PRIMARY CARE & SPORTS MEDICINE INSTITUTE LLC
Entity type:Organization
Organization Name:NORTH JERSEY PRIMARY CARE & SPORTS MEDICINE INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:RUSSONELLA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:973-340-1940
Mailing Address - Street 1:6 BRIGHTON ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07012-1647
Mailing Address - Country:US
Mailing Address - Phone:973-340-1940
Mailing Address - Fax:973-340-1958
Practice Address - Street 1:6 BRIGHTON ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07012-1647
Practice Address - Country:US
Practice Address - Phone:973-340-1940
Practice Address - Fax:973-340-1958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-02
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08676900261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ224841YAT3OtherMEDICARE PTAN