Provider Demographics
NPI:1588624415
Name:MARTHA'S VINEYARD ORTHOPEDIC SURGERY AND SPORTS MEDICINE
Entity Type:Organization
Organization Name:MARTHA'S VINEYARD ORTHOPEDIC SURGERY AND SPORTS MEDICINE
Other - Org Name:MONTO ORTHOPEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:ROCCO
Authorized Official - Last Name:MONTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-693-5949
Mailing Address - Street 1:PO BOX 547
Mailing Address - Street 2:
Mailing Address - City:WEST TISBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02575-0547
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 COURNOYER ROAD
Practice Address - Street 2:
Practice Address - City:WEST TISBURY
Practice Address - State:MA
Practice Address - Zip Code:02575-0547
Practice Address - Country:US
Practice Address - Phone:508-693-5949
Practice Address - Fax:508-693-0319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-24
Last Update Date:2007-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9703217Medicaid
MAM17719OtherBLUE CROSS BLUE SHIELD
AA39271OtherHARVARD PILGRIM PT GROUP
MAY61175OtherBC/BS PT GROUP
MAY61175OtherBC/BS PT GROUP
MA9703217Medicaid