=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336346063
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAPE COD FAMILY PRACTICE & SPORTS MEDICINE, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2007
-----------------------------------------------------
Last Update Date | 04/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34 BATES RD SUITE 202
-----------------------------------------------------
City | MASHPEE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02649-3280
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-539-3353
-----------------------------------------------------
Fax | 508-539-6848
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 595
-----------------------------------------------------
City | MASHPEE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02649-0595
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-539-3353
-----------------------------------------------------
Fax | 508-539-6848
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. JENNIFER MOSYCHUK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 508-539-3353
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 204C00000X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Neuromusculoskeletal Medicine) Physician
-----------------------------------------------------
License Number | 210923
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 210923
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------