Healthcare Provider Details

I. General information

NPI: 1336346063
Provider Name (Legal Business Name): CAPE COD FAMILY PRACTICE & SPORTS MEDICINE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 04/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 BATES RD SUITE 202
MASHPEE MA
02649-3280
US

IV. Provider business mailing address

PO BOX 595
MASHPEE MA
02649-0595
US

V. Phone/Fax

Practice location:
  • Phone: 508-539-3353
  • Fax: 508-539-6848
Mailing address:
  • Phone: 508-539-3353
  • Fax: 508-539-6848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number210923
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number210923
License Number StateMA

VIII. Authorized Official

Name: MRS. JENNIFER MOSYCHUK
Title or Position: OFFICE MANAGER
Credential:
Phone: 508-539-3353