Healthcare Provider Details

I. General information

NPI: 1518971811
Provider Name (Legal Business Name): PRO SPORTS ORTHOPEDICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 06/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 GUEST ST STE 225
BRIGHTON MA
02135-2065
US

IV. Provider business mailing address

20 GUEST ST STE 225
BRIGHTON MA
02135-2065
US

V. Phone/Fax

Practice location:
  • Phone: 617-738-8642
  • Fax: 617-202-4172
Mailing address:
  • Phone: 617-738-8642
  • Fax: 617-202-4172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number
License Number State
# 11
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: LINDA M SURRO
Title or Position: SYSTEMS PROJECT MANAGER
Credential:
Phone: 617-491-6766