1518971811 NPI number — PRO SPORTS ORTHOPEDICS INC

Table of content: (NPI 1518971811)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518971811 NPI number — PRO SPORTS ORTHOPEDICS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRO SPORTS ORTHOPEDICS INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ASSOCIATES IN ORTHOPAEDICS AND SPORTS MEDICINE INC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518971811
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20 GUEST ST STE 225
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRIGHTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02135-2065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-738-8642
Provider Business Mailing Address Fax Number:
617-202-4172

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 GUEST ST STE 225
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIGHTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02135-2065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-738-8642
Provider Business Practice Location Address Fax Number:
617-202-4172
Provider Enumeration Date:
07/29/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SURRO
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
SYSTEMS PROJECT MANAGER
Authorized Official Telephone Number:
617-491-6766

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207XS0114X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XS0117X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0005X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0105X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 247100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 110070879A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".