Provider Demographics
NPI:1447405428
Name:ELITE SPORTS MEDICINE
Entity Type:Organization
Organization Name:ELITE SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:D
Authorized Official - Last Name:KINEMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-266-4908
Mailing Address - Street 1:2315 SUNSET BLVD
Mailing Address - Street 2:SUITE F
Mailing Address - City:STEUBENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43952-2496
Mailing Address - Country:US
Mailing Address - Phone:740-266-4908
Mailing Address - Fax:740-264-4376
Practice Address - Street 1:110 MAIN ST
Practice Address - Street 2:
Practice Address - City:WINTERSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43953-3734
Practice Address - Country:US
Practice Address - Phone:740-266-4908
Practice Address - Fax:740-264-4376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-18
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3007749Medicaid
OH=========00OtherBWC
OH=========00OtherBWC