MEDICARE: PREMIER ORTHOPAEDICS AND SPORTS MEDICINE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist		PA

General Provider Information

NPI Number	:	1255503181
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER ORTHOPAEDICS AND SPORTS MEDICINE

Provider Business Mailing Address
First Line	:	PO BOX 81
Second Line	:
City	:	BRYN MAWR
State	:	PA
Zip	:	19010-0081
Country	:	US
Telephone Number	:	610-876-0347
Fax Number	:	610-872-4759

Provider Business Practice Location Address
First Line	:	ONE MEDICAL CENTER BLVD.
Second Line	:	POB II, SUITE 324
City	:	UPLAND
State	:	PA
Zip	:	19015
Country	:	US
Telephone Number	:	610-876-0347
Fax Number	:	610-872-4759

Authorized Official
Title or Position	:	BILLING CLERK
Name	:	JODY FRY
Credential	:
Telephone Number	:	610-876-0347

Provider Enumeration Date	:	04/01/2008
Last Update Date	:	07/21/2022

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