MEDICARE: US SPORTS MEDICINE, LLC

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	261QR0200X	Radiology Clinic/Center
2	2085R0202X	Diagnostic Radiology Physician

General Provider Information

NPI Number	:	1487296505
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	US SPORTS MEDICINE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 741804
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90074-1804
Country	:	US
Telephone Number	:	866-674-7933
Fax Number	:	952-513-6880

Provider Business Practice Location Address
First Line	:	1178 E BRICKYARD RD
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2555
Country	:	US
Telephone Number	:	801-563-0333
Fax Number	:	801-563-0335

Authorized Official
Title or Position	:	SPECIAL ASSISTANT SECRETARY
Name	:	MS. RAMONA L AHERN
Credential	:
Telephone Number	:	952-738-4441

Provider Enumeration Date	:	10/09/2019
Last Update Date	:	08/11/2021

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Directions to “US SPORTS MEDICINE, LLC ” Practice Location

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