Basic Information
| Provider Information | |||||||||
| NPI: | 1891191201 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RECONSTRUCTIVE ORTHOPEDICS, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 EVES DR # A | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MARLTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080533195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6092679400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 570 EGG HARBOR RD | ||||||||
| Address2: | SUITE C-4 | ||||||||
| City: | SEWELL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080802359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6092679400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2014 | ||||||||
| LastUpdateDate: | 11/12/2014 | ||||||||
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| AuthorizedOfficialLastName: | MICKLE | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 6092679400 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RECONSTRUCTIVE ORTHOPEDICS, P.A. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081P2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.