Healthcare Provider Details

I. General information

NPI: 1629053814
Provider Name (Legal Business Name): SPECIALIZED ORTHOPAEDICS & SPORTS MEDICINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 11/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 E BROAD ST SUITE 100
COLUMBUS OH
43215-3947
US

IV. Provider business mailing address

720 E BROAD ST SUITE 100
COLUMBUS OH
43215-3947
US

V. Phone/Fax

Practice location:
  • Phone: 614-461-6634
  • Fax: 614-461-1730
Mailing address:
  • Phone: 614-461-6634
  • Fax: 614-461-1730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ROBERT E. BARTLEY
Title or Position: PRESIDENT
Credential: MD
Phone: 614-461-6634