MEDICARE: ELITE SPORTS MEDICINE AND ORTHOPAEDIC CENTER, PLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3732025	OTHER	TN	GROUP MEDICARE NUMBER

General Provider Information

NPI Number	:	1366868747
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELITE SPORTS MEDICINE AND ORTHOPAEDIC CENTER, PLC

Provider Business Mailing Address
First Line	:	2004 HAYES ST
Second Line	:	SUITE 200
City	:	NASHVILLE
State	:	TN
Zip	:	37203-2646
Country	:	US
Telephone Number	:	615-284-2000
Fax Number	:	615-284-2003

Provider Business Practice Location Address
First Line	:	1616 W MAIN ST
Second Line	:	SUITE 203
City	:	LEBANON
State	:	TN
Zip	:	37087-3100
Country	:	US
Telephone Number	:	615-284-2000
Fax Number	:	615-284-2003

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	JUSTIN LAWSON
Credential	:	CPA
Telephone Number	:	615-284-2000

Provider Enumeration Date	:	03/10/2014
Last Update Date	:	01/08/2021

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