Provider Demographics
NPI:1407034994
Name:SPORTS MEDICINE ORTHOPAEDICS & PODIATRY INC
Entity Type:Organization
Organization Name:SPORTS MEDICINE ORTHOPAEDICS & PODIATRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:D
Authorized Official - Last Name:GOLDSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-383-7753
Mailing Address - Street 1:400 MASSASOIT AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914-2020
Mailing Address - Country:US
Mailing Address - Phone:401-383-7753
Mailing Address - Fax:401-383-8982
Practice Address - Street 1:400 MASSASOIT AVENUE
Practice Address - Street 2:SUITE 201
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-2012
Practice Address - Country:US
Practice Address - Phone:401-383-7753
Practice Address - Fax:401-383-8982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9020116Medicaid