Basic Information
| Provider Information | |||||||||
| NPI: | 1750371738 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPEDICS AND SPORTS MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 460 TOTTEN POND RD | ||||||||
| Address2: | |||||||||
| City: | WALTHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024511991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818909933 | ||||||||
| FaxNumber: | 7818909950 | ||||||||
| Practice Location | |||||||||
| Address1: | 825 WASHINGTON ST | ||||||||
| Address2: | STE 260 | ||||||||
| City: | NORWOOD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020623441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817692330 | ||||||||
| FaxNumber: | 7817690860 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MEBEL | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7817692330 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | M11233 | 01 | MA | BCBS | OTHER | 600354 | 01 | MA | TUFTS | OTHER | 9718362 | 05 | MA | MEDICAID |