Basic Information
| Provider Information | |||||||||
| NPI: | 1891447173 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH SHORE CENTER FOR ORTHOPEDIC SURGERY & SPORTS MEDICINE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 STATE RD | ||||||||
| Address2: | |||||||||
| City: | DANVERS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019232567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9787743400 | ||||||||
| FaxNumber: | 9787745883 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 STATE RD | ||||||||
| Address2: | |||||||||
| City: | DANVERS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019232567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9787743400 | ||||||||
| FaxNumber: | 9787745883 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2022 | ||||||||
| LastUpdateDate: | 01/19/2022 | ||||||||
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| AuthorizedOfficialLastName: | PETERSON | ||||||||
| AuthorizedOfficialFirstName: | STACY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9787743400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | 01/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.