Healthcare Provider Details

I. General information

NPI: 1184944167
Provider Name (Legal Business Name): PREMIER ORTHOPAEDIC AND SPORTS MEDICINE ASSOCIATES, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2010
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BARTOL AVE STE 100
RIDLEY PARK PA
19078-2214
US

IV. Provider business mailing address

PO BOX 5228
WEST CHESTER PA
19380-0405
US

V. Phone/Fax

Practice location:
  • Phone: 610-521-8970
  • Fax: 610-521-3983
Mailing address:
  • Phone: 610-359-6571
  • Fax: 610-521-3983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: KIM STOTT
Title or Position: ADMINISTRATIVE MANAGER
Credential:
Phone: 610-359-5664