Basic Information
Provider Information | |||||||||
NPI: | 1184944167 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PREMIER ORTHOPAEDIC AND SPORTS MEDICINE ASSOCIATES, LTD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5228 | ||||||||
Address2: |   | ||||||||
City: | WEST CHESTER | ||||||||
State: | PA | ||||||||
PostalCode: | 193800405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6103596571 | ||||||||
FaxNumber: | 6105213983 | ||||||||
Practice Location | |||||||||
Address1: | 1 BARTOL AVE | ||||||||
Address2: | STE 100 | ||||||||
City: | RIDLEY PARK | ||||||||
State: | PA | ||||||||
PostalCode: | 190782214 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6105218970 | ||||||||
FaxNumber: | 6105213983 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2010 | ||||||||
LastUpdateDate: | 02/10/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STOTT | ||||||||
AuthorizedOfficialFirstName: | KIM | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6103595664 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/10/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RS0010X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sports Medicine | 332B00000X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 207X00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
No ID Information.