1912099961 NPI number — SPORTS MEDICINE INC.

Table of content: (NPI 1912099961)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912099961 NPI number — SPORTS MEDICINE INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPORTS MEDICINE 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:
6
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:
1912099961
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
306A HIGH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENFIELD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-773-3379
Provider Business Mailing Address Fax Number:
413-772-2705

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
306A HIGH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENFIELD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-773-3379
Provider Business Practice Location Address Fax Number:
413-772-2705
Provider Enumeration Date:
09/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
REID
Authorized Official Middle Name:
JEFFRIES
Authorized Official Title or Position:
OWNER / TREASURER
Authorized Official Telephone Number:
413-773-3379

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9750746 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: Y65552 . This is a "BCBS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 2837637 . This is a "AETNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 15116 . This is a "HEALTH NEW ENGLAND" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 615742 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 606146 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 20762 . This is a "FALLON" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 754960 . This is a "CONNECTICARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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