Provider Demographics
NPI:1295816460
Name:ROCHESTER KNEE & SPORTS MEDICINE, PC
Entity Type:Organization
Organization Name:ROCHESTER KNEE & SPORTS MEDICINE, PC
Other - Org Name:CENTER FOR ADVANCED ORTHOPEDICS AND SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:DAYNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DELOZIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-484-2128
Mailing Address - Street 1:3100 CROSS CREEK PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:AUBURN HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48326-2776
Mailing Address - Country:US
Mailing Address - Phone:248-377-8000
Mailing Address - Fax:248-377-2929
Practice Address - Street 1:3100 CROSS CREEK PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-2774
Practice Address - Country:US
Practice Address - Phone:248-377-8000
Practice Address - Fax:248-377-2929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic FitterGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherTAX ID
MI5148130001Medicare NSC