Healthcare Provider Details

I. General information

NPI: 1508425992
Provider Name (Legal Business Name): PREMIER ORTHOPAEDIC AND SPORTS MEDICINE ASSOCIATES LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2019
Last Update Date: 06/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 WOODVIEW RD STE 205
WEST GROVE PA
19390-9315
US

IV. Provider business mailing address

915 OLD FERN HILL ROAD BLDG A STE 1
WEST CHESTER PA
19380-4269
US

V. Phone/Fax

Practice location:
  • Phone: 484-748-6148
  • Fax: 610-869-2320
Mailing address:
  • Phone: 610-692-6280
  • Fax: 610-429-1943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: HEATHER DEFAZIO
Title or Position: EXECUTIVE ASSISTANT
Credential:
Phone: 610-692-6280