Basic Information
| Provider Information | |||||||||
| NPI: | 1629311691 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELITE SPORTS MEDICINE AND ORTHOPAEDIC CENTER, PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2004 HAYES ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372032646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152842000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5021 CAROTHERS PARKWAY | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153241600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2013 | ||||||||
| LastUpdateDate: | 05/04/2022 | ||||||||
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| AuthorizedOfficialLastName: | LAWSON | ||||||||
| AuthorizedOfficialFirstName: | JUSTIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6152842000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | 04/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | N | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist | 207XS0106X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XS0117X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207XX0004X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207XX0005X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3732025 | 05 | TN | MEDICAID | 3732025 | 01 | TN | GROUP MEDICARE NUMBER | OTHER |