Provider Demographics
NPI:1508859463
Name:HIGH PERFORMANCE SPORTS MEDICINE, PC
Entity Type:Organization
Organization Name:HIGH PERFORMANCE SPORTS MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:P
Authorized Official - Last Name:GILLIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-921-7590
Mailing Address - Street 1:900 CUMMINGS CTR
Mailing Address - Street 2:SUITE 130-U
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-6198
Mailing Address - Country:US
Mailing Address - Phone:978-921-7590
Mailing Address - Fax:978-921-7597
Practice Address - Street 1:900 CUMMINGS CTR
Practice Address - Street 2:SUITE 130-U
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-6198
Practice Address - Country:US
Practice Address - Phone:978-921-7590
Practice Address - Fax:978-921-7597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-25
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0756OtherRAILROAD MEDICARE
MA9723820Medicaid
MAM18148OtherBLUE CROSS BLUE SHIELD
171031OtherHARVARD PILGRIM
693840OtherTUFTS HEALTH PLAN
2998140OtherAETNA
M21205OtherMEDICARE PTAN
0028303OtherNEIGHBORHOOD HEALTH PLAN
MAM18148OtherBLUE CROSS BLUE SHIELD
=========OtherCIGNA
=========OtherFALLON COMMUNITY HEALTH
693840OtherTUFTS HEALTH PLAN
M21205OtherMEDICARE PTAN
2998140OtherAETNA