Provider Demographics
NPI:1164465266
Name:MARTHA'S VINEYARD ORTHOPEDIC SURGERY AND SPORTS MEDICINE
Entity Type:Organization
Organization Name:MARTHA'S VINEYARD ORTHOPEDIC SURGERY AND SPORTS MEDICINE
Other - Org Name:MONTO ORTHOPEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:R
Authorized Official - Last Name:MONTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-693-5949
Mailing Address - Street 1:PO BOX 547
Mailing Address - Street 2:12 COURNOYER RD
Mailing Address - City:WEST TISBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02575-0547
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 COURNOYER RD
Practice Address - Street 2:
Practice Address - City:WEST TISBURY
Practice Address - State:MA
Practice Address - Zip Code:02575-0547
Practice Address - Country:US
Practice Address - Phone:508-693-5949
Practice Address - Fax:508-693-0319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA5144470001Medicare NSC