Provider Demographics
NPI:1205379989
Name:ELITE SPORTS MEDICINE AND ORTHOPAEDIC CENTER, PLC
Entity Type:Organization
Organization Name:ELITE SPORTS MEDICINE AND ORTHOPAEDIC CENTER, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CLAUDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAGACY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-342-0264
Mailing Address - Street 1:PO BOX 896172
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6172
Mailing Address - Country:US
Mailing Address - Phone:615-324-1600
Mailing Address - Fax:615-284-2003
Practice Address - Street 1:356 24TH AVE NORTH
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1519
Practice Address - Country:US
Practice Address - Phone:615-324-1600
Practice Address - Fax:615-284-2003
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELITE SPORTS MEDICINE AND ORTHOPAEDIC CENTER, PLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-11-29
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN207QS0010X, 207RC0000X, 207X00000X, 207XS0106X, 207XS0117X, 207XX0004X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Multi-Specialty
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3732025Medicare UPIN