Basic Information
| Provider Information | |||||||||
| NPI: | 1659750834 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPORT ORTHO URGENT CARE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4998 CROSSINGS CIR STE 200 | ||||||||
| Address2: | |||||||||
| City: | MOUNT JULIET | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371220018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6155535000 | ||||||||
| FaxNumber: | 6157583875 | ||||||||
| Practice Location | |||||||||
| Address1: | 4998 CROSSINGS CIR STE 200 | ||||||||
| Address2: | |||||||||
| City: | MOUNT JULIET | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371220018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6155535000 | ||||||||
| FaxNumber: | 6157583875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2015 | ||||||||
| LastUpdateDate: | 07/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | KAELIN | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6155535000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 07/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 261QU0200X | TN | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | Q021469 | 05 | TN | MEDICAID |