Organization
SPORTS EXTRA PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MICHELE THERESA GILSENAN D.O. (PRACTICE OWNER)
(732) 388-7300
Entity
Organization
Contact information
Practice address
67 WALNUT AVE, SUITE 202, CLARK, NJ 07066-1640
(732) 388-7300
(732) 388-1330
Mailing address
67 WALNUT AVE, SUITE 202, CLARK, NJ 07066-1640
(732) 388-7300
(732) 388-1330
Taxonomy
Speciality
Code
Description
License number
State
207QS0010X
Sports Medicine (Family Medicine) Physician
Primary
—
—
Other
Enumeration date
05/25/2006
Last updated
10/18/2007
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