Basic Information
| Provider Information | |||||||||
| NPI: | 1093769101 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAPE COD ORTHOPEDICS AND SPORTS MEDICINE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18 ROUTE 6A | ||||||||
| Address2: | |||||||||
| City: | SANDWICH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 025632019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087758282 | ||||||||
| FaxNumber: | 5087751414 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 NORTH ST | ||||||||
| Address2: | |||||||||
| City: | HYANNIS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026013825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087758282 | ||||||||
| FaxNumber: | 5087751414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 03/26/2019 | ||||||||
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| AuthorizedOfficialLastName: | WILLIS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5087789336 | ||||||||
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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 | 9773983 | 05 | MA | MEDICAID |