Provider Demographics
NPI:1639478894
Name:FAST TRACK SPINE AND SPORTS MEDICINE LLC
Entity Type:Organization
Organization Name:FAST TRACK SPINE AND SPORTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:412-855-7430
Mailing Address - Street 1:1643 W LANE AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43221-3339
Mailing Address - Country:US
Mailing Address - Phone:614-775-1503
Mailing Address - Fax:614-317-3001
Practice Address - Street 1:1643 W LANE AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-3339
Practice Address - Country:US
Practice Address - Phone:614-775-1503
Practice Address - Fax:614-775-1503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-26
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-0088642208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty