Provider Demographics
NPI:1174612832
Name:SPINE CENTER AND ORTHOPEDIC REHABILITATION OF ENGLEWOOD, PC
Entity type:Organization
Organization Name:SPINE CENTER AND ORTHOPEDIC REHABILITATION OF ENGLEWOOD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:PETROCELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-503-1900
Mailing Address - Street 1:106 GRAND AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-3574
Mailing Address - Country:US
Mailing Address - Phone:201-503-1900
Mailing Address - Fax:201-503-1901
Practice Address - Street 1:106 GRAND AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-3574
Practice Address - Country:US
Practice Address - Phone:201-503-1900
Practice Address - Fax:201-503-1901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01172600261QP2000X
NJ25MA05923000261QP3300X, 261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Not Answered261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Not Answered261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ095526Medicare ID - Type UnspecifiedBILLING ID