Basic Information
| Provider Information | |||||||||
| NPI: | 1730257684 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADVANTAGE SPORTS MEDICINE & PHYSICAL THERAPY,INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 245 NORTH STREET | ||||||||
| Address2: | |||||||||
| City: | STONEHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814387221 | ||||||||
| FaxNumber: | 7814387208 | ||||||||
| Practice Location | |||||||||
| Address1: | 245 NORTH STREET | ||||||||
| Address2: | |||||||||
| City: | STONEHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814387221 | ||||||||
| FaxNumber: | 7814387208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 02/25/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LAMB | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7814387221 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT, SCS, ATC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | Y65648 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER | 616931 | 01 | MA | HARVARD PILGRIM HEALTH | OTHER | 715078 | 01 | MA | TUFTS HEALTH PLAN | OTHER |