1689956831 NPI number — SPORTS MEDICINE NORTH ORTHOPAEDIC SURGERY, INC

Table of content: (NPI 1689956831)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689956831 NPI number — SPORTS MEDICINE NORTH ORTHOPAEDIC SURGERY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPORTS MEDICINE NORTH ORTHOPAEDIC SURGERY, 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:
Provider Other Organization Name Type Code:
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:
1689956831
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 ORTHOPEDICS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEABODY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01960-1668
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-818-6350
Provider Business Mailing Address Fax Number:
978-818-6355

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 BLACKBURN DR
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
GLOUCESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01930-2237
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-818-6350
Provider Business Practice Location Address Fax Number:
978-818-6355
Provider Enumeration Date:
09/14/2011

Additional Information

Authorized Official

Authorized Official Last Name:
POLANSKY
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
978-818-6350

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: M15814 . This is a "MEDICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9773363 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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