Basic Information
| Provider Information | |||||||||
| NPI: | 1083617625 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPAEDIC AND SPORTS MEDICINE CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 108 FORBES ST | ||||||||
| Address2: | |||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214011502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102688862 | ||||||||
| FaxNumber: | 4102804701 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 FORBES ST | ||||||||
| Address2: | |||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214011502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102688862 | ||||||||
| FaxNumber: | 4102804701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 12/17/2007 | ||||||||
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| AuthorizedOfficialLastName: | CHAPUT | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR CEO | ||||||||
| AuthorizedOfficialTelephone: | 4102688862 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 146000500 | 05 | MD | MEDICAID |