Healthcare Provider Details

I. General information

NPI: 1083617625
Provider Name (Legal Business Name): ORTHOPAEDIC AND SPORTS MEDICINE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 12/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 FORBES ST
ANNAPOLIS MD
21401-1502
US

IV. Provider business mailing address

108 FORBES ST
ANNAPOLIS MD
21401-1502
US

V. Phone/Fax

Practice location:
  • Phone: 410-268-8862
  • Fax: 410-280-4701
Mailing address:
  • Phone: 410-268-8862
  • Fax: 410-280-4701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. MARK CHAPUT
Title or Position: ADMINISTRATOR CEO
Credential:
Phone: 410-268-8862