Healthcare Provider Details

I. General information

NPI: 1861680720
Provider Name (Legal Business Name): CHILDREN'S SPORTS MEDICINE FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2007
Last Update Date: 10/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 LONGWOOD AVE
BOSTON MA
02115-5728
US

IV. Provider business mailing address

PO BOX 3694
BOSTON MA
02241-3694
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-5971
  • Fax: 617-730-0178
Mailing address:
  • Phone: 508-946-1665
  • Fax: 508-947-1293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: LYLE J MICHELI
Title or Position: DIRECTOR
Credential: M.D.
Phone: 617-355-5971