Provider Demographics
NPI:1356688170
Name:BOSTON ORTHOPEDIC & SPORT MEDICINE
Entity Type:Organization
Organization Name:BOSTON ORTHOPEDIC & SPORT MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:K
Authorized Official - Last Name:RITTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-782-7772
Mailing Address - Street 1:1505 COMMONWEALTH AVE
Mailing Address - Street 2:SUITE 340
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-3605
Mailing Address - Country:US
Mailing Address - Phone:617-782-7772
Mailing Address - Fax:
Practice Address - Street 1:1505 COMMONWEALTH AVE
Practice Address - Street 2:SUITE 340
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-3605
Practice Address - Country:US
Practice Address - Phone:617-782-7772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA45262174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9740376Medicaid