Healthcare Provider Details

I. General information

NPI: 1316395361
Provider Name (Legal Business Name): SPORTS GROUP PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 06/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1718 MASSACHUSETTS AVE
CAMBRIDGE MA
02138-1804
US

IV. Provider business mailing address

1718 MASSACHUSETTS AVE
CAMBRIDGE MA
02138-1804
US

V. Phone/Fax

Practice location:
  • Phone: 617-492-5438
  • Fax: 617-868-4611
Mailing address:
  • Phone: 617-492-5438
  • Fax: 617-868-4611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateMA

VIII. Authorized Official

Name: DR. THOMAS JAMES HAGAN
Title or Position: DIRECTOR
Credential: D.C.
Phone: 617-492-5438