Healthcare Provider Details

I. General information

NPI: 1164465266
Provider Name (Legal Business Name): MARTHA'S VINEYARD ORTHOPEDIC SURGERY AND SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 COURNOYER RD
WEST TISBURY MA
02575-0547
US

IV. Provider business mailing address

PO BOX 547 12 COURNOYER RD
WEST TISBURY MA
02575-0547
US

V. Phone/Fax

Practice location:
  • Phone: 508-693-5949
  • Fax: 508-693-0319
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: RAYMOND R MONTO
Title or Position: CEO
Credential: M.D.
Phone: 508-693-5949