Healthcare Provider Details

I. General information

NPI: 1891447173
Provider Name (Legal Business Name): NORTH SHORE CENTER FOR ORTHOPEDIC SURGERY & SPORTS MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2022
Last Update Date: 01/19/2022
Certification Date: 01/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 STATE RD
DANVERS MA
01923-2567
US

IV. Provider business mailing address

4 STATE RD
DANVERS MA
01923-2567
US

V. Phone/Fax

Practice location:
  • Phone: 978-774-3400
  • Fax: 978-774-5883
Mailing address:
  • Phone: 978-774-3400
  • Fax: 978-774-5883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. STACY M PETERSON
Title or Position: OWNER/MANAGER
Credential: D.O.
Phone: 978-774-3400