Provider Demographics
NPI:1205211331
Name:SPORTS MEDICINE HEALTH LLC
Entity Type:Organization
Organization Name:SPORTS MEDICINE HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRASIER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:508-356-7788
Mailing Address - Street 1:35 UNITED DR STE 102
Mailing Address - Street 2:
Mailing Address - City:WEST BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02379-1056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:730 MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:MILLIS
Practice Address - State:MA
Practice Address - Zip Code:02054-1612
Practice Address - Country:US
Practice Address - Phone:508-356-7788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-30
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA26380207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9775285Medicaid
MA9775285Medicaid