Basic Information
Provider Information | |||||||||
NPI: | 1124526421 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RECONSTRUCTIVE ORTHOPEDICS, P.A. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4 EVES DR STE A100 | ||||||||
Address2: |   | ||||||||
City: | MARLTON | ||||||||
State: | NJ | ||||||||
PostalCode: | 080533126 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6092679400 | ||||||||
FaxNumber: | 6092679457 | ||||||||
Practice Location | |||||||||
Address1: | 131 ROUTE 70 | ||||||||
Address2: |   | ||||||||
City: | MEDFORD | ||||||||
State: | NJ | ||||||||
PostalCode: | 08055 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6092679400 | ||||||||
FaxNumber: | 6092679457 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/01/2018 | ||||||||
LastUpdateDate: | 02/01/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LITT | ||||||||
AuthorizedOfficialFirstName: | MICKA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
AuthorizedOfficialTelephone: | 6092679400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
No ID Information.