Basic Information
| Provider Information | |||||||||
| NPI: | 1063487577 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPORTS MEDICINE ASSOCIATES P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2200 | ||||||||
| Address2: | |||||||||
| City: | AMHERST | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030314200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036739411 | ||||||||
| FaxNumber: | 6036739899 | ||||||||
| Practice Location | |||||||||
| Address1: | 830 BOYLSTON ST | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | BROOKLINE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024672503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177392003 | ||||||||
| FaxNumber: | 6177340242 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2006 | ||||||||
| LastUpdateDate: | 02/25/2010 | ||||||||
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| AuthorizedOfficialLastName: | HESTER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6177392003 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204C00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine, Sports Medicine | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0021510 | 01 | MA | NEIGHBORHOOD HEALTH PLAN | OTHER | 49108 | 01 | MA | FALLON COMMUNITY HEALTH | OTHER | M17672 | 01 | MA | BCBS OF MA | OTHER | VC6000189233 | 01 | MA | MA WORKERS COMPENSATION | OTHER | 687403 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 103363500 | 01 | FEDERAL WORKERS COMP | OTHER | 9703420 | 05 | MA | MEDICAID | 2436362 | 01 | MA | AETNA | OTHER |