Basic Information
Provider Information | |||||||||
NPI: | 1386957470 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SPORTSMEDICINE ATLANTIC ORTHOPAEDICS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 150 US HIGHWAY 1 BYP | ||||||||
Address2: |   | ||||||||
City: | PORTSMOUTH | ||||||||
State: | NH | ||||||||
PostalCode: | 038015332 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6034311121 | ||||||||
FaxNumber: | 6034313347 | ||||||||
Practice Location | |||||||||
Address1: | 16 HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | YORK | ||||||||
State: | ME | ||||||||
PostalCode: | 039091011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2073633490 | ||||||||
FaxNumber: | 6034313347 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2010 | ||||||||
LastUpdateDate: | 07/19/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NOERDLINGER | ||||||||
AuthorizedOfficialFirstName: | MAYO | ||||||||
AuthorizedOfficialMiddleName: | ANDREW | ||||||||
AuthorizedOfficialTitleorPosition: | PHYSICIAN/PARTNER | ||||||||
AuthorizedOfficialTelephone: | 6034311121 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 015677 | ME | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 1232140001 | 01 | ME | MEDICARE DME/POS | OTHER |