Basic Information
| Provider Information | |||||||||
| NPI: | 1366868747 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELITE SPORTS MEDICINE AND ORTHOPAEDIC CENTER, PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2004 HAYES ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372032646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152842000 | ||||||||
| FaxNumber: | 6152842003 | ||||||||
| Practice Location | |||||||||
| Address1: | 1616 W MAIN ST | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | LEBANON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370873100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152842000 | ||||||||
| FaxNumber: | 6152842003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2014 | ||||||||
| LastUpdateDate: | 01/08/2021 | ||||||||
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| AuthorizedOfficialLastName: | LAWSON | ||||||||
| AuthorizedOfficialFirstName: | JUSTIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6152842000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | 01/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 3732025 | 01 | TN | GROUP MEDICARE NUMBER | OTHER |