=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063487577
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPORTS MEDICINE ASSOCIATES P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2006
-----------------------------------------------------
Last Update Date | 02/25/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 830 BOYLSTON ST SUITE 205
-----------------------------------------------------
City | BROOKLINE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02467-2503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-739-2003
-----------------------------------------------------
Fax | 617-734-0242
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2200
-----------------------------------------------------
City | AMHERST
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03031-4200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-673-9411
-----------------------------------------------------
Fax | 603-673-9899
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOHN T. HESTER
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 617-739-2003
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 204C00000X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Neuromusculoskeletal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------