Healthcare Provider Details

I. General information

NPI: 1538227707
Provider Name (Legal Business Name): SPORTS ORTHOPEDIC AND REHABILITATION MEDICINE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 ARGUELLO ST STE 100
REDWOOD CITY CA
94063-1566
US

IV. Provider business mailing address

500 ARGUELLO ST
REDWOOD CITY CA
94063-1566
US

V. Phone/Fax

Practice location:
  • Phone: 650-851-4900
  • Fax: 408-556-8415
Mailing address:
  • Phone: 650-851-4900
  • Fax: 408-556-8415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MALLIKA BASU
Title or Position: MANAGER
Credential:
Phone: 408-556-8407