=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245439595
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORTHOPAEDIC AND SPORTS MEDICINE CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2007
-----------------------------------------------------
Last Update Date | 12/17/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4175 N HANSON CT SUITE 301
-----------------------------------------------------
City | BOWIE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20716-3179
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-805-0190
-----------------------------------------------------
Fax | 301-352-0173
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 108 FORBES ST
-----------------------------------------------------
City | ANNAPOLIS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21401-1502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-268-8862
-----------------------------------------------------
Fax | 410-280-4701
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. MARK R CHAPUT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 410-268-8862
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XX0005X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------