Basic Information
| Provider Information | |||||||||
| NPI: | 1093288615 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRECISION ORTHOPEDICS AND SPORTS MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14201 PARK CENTER DR STE 410 | ||||||||
| Address2: | |||||||||
| City: | LAUREL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207075251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014980383 | ||||||||
| FaxNumber: | 3016180594 | ||||||||
| Practice Location | |||||||||
| Address1: | 14201 PARK CENTER DR STE 410 | ||||||||
| Address2: | |||||||||
| City: | LAUREL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207075251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014980383 | ||||||||
| FaxNumber: | 3016180594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2019 | ||||||||
| LastUpdateDate: | 07/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | BOATMAN | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | LEA | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3014980340 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRECISION ORTHPEDICS AND SPORTS MEDICINE | ||||||||
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| NPICertificationDate: | 07/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 4211326203 | 05 | MD | MEDICAID |