Healthcare Provider Details

I. General information

NPI: 1619163052
Provider Name (Legal Business Name): BOSTON SPORTS & SHOULDER CENTER,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 ALLIED DR
DEDHAM MA
02026-6146
US

IV. Provider business mailing address

840 WINTER ST
WALTHAM MA
02451-1433
US

V. Phone/Fax

Practice location:
  • Phone: 617-264-1100
  • Fax: 617-264-1101
Mailing address:
  • Phone: 781-890-2133
  • Fax: 781-890-2177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JONATHAN SHAKER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 781-890-2133