=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780806240
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROGRESSIVE SPORTS MEDICINE, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 04/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 404 MCFARLAN RD SUITE 201
-----------------------------------------------------
City | KENNETT SQUARE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19348-2479
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-444-5406
-----------------------------------------------------
Fax | 610-444-5907
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 404 MCFARLAN RD SUITE 201
-----------------------------------------------------
City | KENNETT SQUARE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19348-2479
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-444-5406
-----------------------------------------------------
Fax | 610-444-5907
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHAEL J. GRAVELEY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 610-444-5406
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------