Provider Demographics
NPI:1356610133
Name:PERFORMANCE SPINE & SPORTS MEDICINE
Entity type:Organization
Organization Name:PERFORMANCE SPINE & SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHIAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WIEDERHOLZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-588-8600
Mailing Address - Street 1:PO BOX 649842
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75264-9842
Mailing Address - Country:US
Mailing Address - Phone:609-817-0052
Mailing Address - Fax:609-588-8602
Practice Address - Street 1:4056 QUAKERBRIDGE RD STE 112
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-4779
Practice Address - Country:US
Practice Address - Phone:609-588-8600
Practice Address - Fax:609-588-8602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-22
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00303700335E00000X
NJ25MA08436100332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ156863Medicare UPIN