Provider Demographics
NPI:1629053814
Name:SPECIALIZED ORTHOPAEDICS & SPORTS MEDICINE, INC.
Entity Type:Organization
Organization Name:SPECIALIZED ORTHOPAEDICS & SPORTS MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:BARTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-461-6634
Mailing Address - Street 1:720 E BROAD ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-3947
Mailing Address - Country:US
Mailing Address - Phone:614-461-6634
Mailing Address - Fax:614-461-1730
Practice Address - Street 1:720 E BROAD ST
Practice Address - Street 2:SUITE 100
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-3947
Practice Address - Country:US
Practice Address - Phone:614-461-6634
Practice Address - Fax:614-461-1730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0621509Medicaid
OHSP9287301Medicare PIN
OH0621509Medicaid