Healthcare Provider Details

I. General information

NPI: 1417219361
Provider Name (Legal Business Name): ORTHOPAEDIC SURGERY AND SPORTS MEDICINE GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2012
Last Update Date: 06/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

254 LANCASTER AVE
MALVERN PA
19355-3087
US

IV. Provider business mailing address

PO BOX 968
PAOLI PA
19301-0968
US

V. Phone/Fax

Practice location:
  • Phone: 610-644-7755
  • Fax:
Mailing address:
  • Phone: 610-644-7755
  • Fax: 610-644-8290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License NumberMD018000E
License Number StatePA

VIII. Authorized Official

Name: DR. LEWIS S SHARPS
Title or Position: VICE PRESIDENT
Credential: M.D.
Phone: 610-644-7755