Provider Demographics
NPI:1588649842
Name:SPORTS MEDICINE GRANT, INC
Entity Type:Organization
Organization Name:SPORTS MEDICINE GRANT, INC
Other - Org Name:SPORTS MEDICINE GRANT & ORTHOPAEDIC ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:J
Authorized Official - Last Name:TESNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-461-8174
Mailing Address - Street 1:323 E TOWN ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-4774
Mailing Address - Country:US
Mailing Address - Phone:614-461-8174
Mailing Address - Fax:614-461-9155
Practice Address - Street 1:323 E TOWN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-4774
Practice Address - Country:US
Practice Address - Phone:614-461-8174
Practice Address - Fax:614-461-9155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCD7823OtherOH RR MDCR (GROUP)
OH0697974Medicaid
WVCK2955OtherWV RR MDCR (GROUP)
WVSP9213476OtherWV MEDICARE GROUP
OHSP9213471Medicare ID - Type UnspecifiedGROUP