Provider Demographics
NPI:1467638312
Name:ADVANCED ORTHOPAEDICS AND SPORTS MEDICINE, LLC
Entity Type:Organization
Organization Name:ADVANCED ORTHOPAEDICS AND SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:F. LINCOLN
Authorized Official - Middle Name:
Authorized Official - Last Name:AVERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:207-332-5462
Mailing Address - Street 1:100 BRICKHILL AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-1999
Mailing Address - Country:US
Mailing Address - Phone:207-773-0040
Mailing Address - Fax:207-774-6501
Practice Address - Street 1:100 FODEN RD
Practice Address - Street 2:SUITE 307
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2327
Practice Address - Country:US
Practice Address - Phone:207-332-5462
Practice Address - Fax:207-774-6501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME012274207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432843300Medicaid
ME432843300Medicaid