Healthcare Provider Details

I. General information

NPI: 1750883195
Provider Name (Legal Business Name): ORTHOBOSTON - BIDC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2018
Last Update Date: 03/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 ROSEMARY ST STE C
NEEDHAM MA
02494-3259
US

IV. Provider business mailing address

PO BOX 2200
AMHERST NH
03031-4200
US

V. Phone/Fax

Practice location:
  • Phone: 617-938-3999
  • Fax:
Mailing address:
  • Phone: 617-938-3999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: TIMOTHY HARTSHORN
Title or Position: OWNER
Credential: MD
Phone: 617-938-3999