Healthcare Provider Details

I. General information

NPI: 1043898018
Provider Name (Legal Business Name): MONTGOMERY SPORTS MEDICINE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6931 ARLINGTON RD STE 550
BETHESDA MD
20814-7217
US

IV. Provider business mailing address

11120 NEW HAMPSHIRE AVE STE 411
SILVER SPRING MD
20904-2620
US

V. Phone/Fax

Practice location:
  • Phone: 301-754-0505
  • Fax: 301-754-0509
Mailing address:
  • Phone: 301-754-0505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: ERAN KESSOUS
Title or Position: DIRECTOR
Credential: MD
Phone: 301-754-0505