Healthcare Provider Details

I. General information

NPI: 1841371143
Provider Name (Legal Business Name): LAKE PLACID SPORTS MEDICINE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 OLD MILITARY RD
LAKE PLACID NY
12946-1738
US

IV. Provider business mailing address

PO BOX 790
LAKE PLACID NY
12946-0790
US

V. Phone/Fax

Practice location:
  • Phone: 518-523-1327
  • Fax: 518-523-9964
Mailing address:
  • Phone: 518-523-1327
  • Fax: 518-523-9964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: KACIE MURPHY
Title or Position: PRACTICE MANAGER
Credential:
Phone: 518-523-1327