Provider Demographics
NPI:1043898018
Name:MONTGOMERY SPORTS MEDICINE CENTER
Entity Type:Organization
Organization Name:MONTGOMERY SPORTS MEDICINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ERAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KESSOUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-754-0505
Mailing Address - Street 1:11120 NEW HAMPSHIRE AVE STE 411
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-2620
Mailing Address - Country:US
Mailing Address - Phone:301-754-0505
Mailing Address - Fax:
Practice Address - Street 1:6931 ARLINGTON RD STE 550
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-7217
Practice Address - Country:US
Practice Address - Phone:301-754-0505
Practice Address - Fax:301-754-0509
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ERAN KESSOUS MD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty