Healthcare Provider Details

I. General information

NPI: 1588624415
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: 03/24/2006
Last Update Date: 11/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 COURNOYER ROAD
WEST TISBURY MA
02575-0547
US

IV. Provider business mailing address

PO BOX 547
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 TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

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