Provider Demographics
NPI:1659750834
Name:SPORT ORTHO URGENT CARE PC
Entity Type:Organization
Organization Name:SPORT ORTHO URGENT CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:KAELIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:615-553-5000
Mailing Address - Street 1:4998 CROSSINGS CIR STE 200
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-0018
Mailing Address - Country:US
Mailing Address - Phone:615-553-5000
Mailing Address - Fax:615-758-3875
Practice Address - Street 1:4998 CROSSINGS CIR STE 200
Practice Address - Street 2:
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-0018
Practice Address - Country:US
Practice Address - Phone:615-553-5000
Practice Address - Fax:615-758-3875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-21
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207XX0005X
TN261QU0200X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ021469Medicaid
TNQ021469Medicaid