MEDICARE: BOSTON SPORTS MEDICINE AND RESEARCH INSTITUTE 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	174400000X	Specialist	152013	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972934529
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOSTON SPORTS MEDICINE AND RESEARCH INSTITUTE LLC

Provider Business Mailing Address
First Line	:	40 ALLIED DR
Second Line	:
City	:	DEDHAM
State	:	MA
Zip	:	02026-6146
Country	:	US
Telephone Number	:	617-264-1100
Fax Number	:	617-264-1101

Provider Business Practice Location Address
First Line	:	40 ALLIED DR
Second Line	:
City	:	DEDHAM
State	:	MA
Zip	:	02026-6146
Country	:	US
Telephone Number	:	617-264-1100
Fax Number	:	617-264-1101

Authorized Official
Title or Position	:	PRESIDENT
Name	:	TOM GILL
Credential	:	MD
Telephone Number	:	617-264-1100

Provider Enumeration Date	:	12/09/2013
Last Update Date	:	05/20/2015

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