Provider Demographics
NPI:1619163052
Name:BOSTON SPORTS & SHOULDER CENTER,LLC
Entity Type:Organization
Organization Name:BOSTON SPORTS & SHOULDER CENTER,LLC
Other - Org Name:BOSTON SPORTS & SHOULDER CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-890-2133
Mailing Address - Street 1:840 WINTER ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1433
Mailing Address - Country:US
Mailing Address - Phone:781-890-2133
Mailing Address - Fax:781-890-2177
Practice Address - Street 1:40 ALLIED DR
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-6146
Practice Address - Country:US
Practice Address - Phone:617-264-1100
Practice Address - Fax:617-264-1101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA648556OtherTUFTS
MA9760920Medicaid
MAM19061OtherBLUE CROSS AND BLUE SHIEL
MA9760920Medicaid
MAM19061OtherBLUE CROSS AND BLUE SHIEL