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General NPI Number Information
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NPI Number | 1407034994
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Entity Type | Organization
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Legal Business Name | SPORTS MEDICINE ORTHOPAEDICS & PODIATRY INC
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Dates
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Enumeration Date | 02/06/2008
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Last Update Date | 12/02/2021
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Provider Practice Location Address
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Address Line | 400 MASSASOIT AVENUE SUITE 201
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City | EAST PROVIDENCE
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State | RI
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Zip | 02914-2012
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Country | US
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Telephone | 401-383-7753
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Fax | 401-383-8982
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Provider Business Mailing Address
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Address Line | 400 MASSASOIT AVE STE 201
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City | EAST PROVIDENCE
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State | RI
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Zip | 02914-2020
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Country | US
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Telephone | 401-383-7753
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Fax | 401-383-8982
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JACK D GOLDSTEIN
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Credential | MD
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Telephone | 401-383-7753
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number |
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License Number State |
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