Basic Information
| Provider Information | |||||||||
| NPI: | 1568905248 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELITE SPORTS MEDICINE AND ORTHOPAEDIC CENTER, PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 896172 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282896172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153241600 | ||||||||
| FaxNumber: | 6152842003 | ||||||||
| Practice Location | |||||||||
| Address1: | 107 GLIDEPATH WAY | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370904133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153241600 | ||||||||
| FaxNumber: | 6152842003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2016 | ||||||||
| LastUpdateDate: | 07/18/2017 | ||||||||
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| AuthorizedOfficialLastName: | LAGACY | ||||||||
| AuthorizedOfficialFirstName: | CLAUDIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6153420264 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ELITE SPORTS MEDICINE AND ORTHOPAEDIC CENTER, PLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | TN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207RC0000X | TN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207X00000X | TN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0106X | TN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XS0117X | TN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207XX0005X | TN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
No ID Information.