Healthcare Provider Details

I. General information

NPI: 1699243402
Provider Name (Legal Business Name): SPORT MEDICINE AND ORTHOPAEDIC CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2018
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5801 HARBOUR VIEW BLVD
SUFFOLK VA
23435-2657
US

IV. Provider business mailing address

501 DISCOVERY DR
CHESAPEAKE VA
23320-3832
US

V. Phone/Fax

Practice location:
  • Phone: 757-547-5145
  • Fax:
Mailing address:
  • Phone: 757-547-5145
  • Fax:

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: DEBRA RUNGE-ASHBY
Title or Position: DIRECTOR OF REVENUE CYCLE
Credential:
Phone: 757-547-5145