Provider Demographics
NPI:1689956831
Name:SPORTS MEDICINE NORTH ORTHOPAEDIC SURGERY, INC
Entity Type:Organization
Organization Name:SPORTS MEDICINE NORTH ORTHOPAEDIC SURGERY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:POLANSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-818-6350
Mailing Address - Street 1:1 ORTHOPEDICS DR
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-1668
Mailing Address - Country:US
Mailing Address - Phone:978-818-6350
Mailing Address - Fax:978-818-6355
Practice Address - Street 1:1 BLACKBURN DR
Practice Address - Street 2:SUITE 5
Practice Address - City:GLOUCESTER
Practice Address - State:MA
Practice Address - Zip Code:01930-2237
Practice Address - Country:US
Practice Address - Phone:978-818-6350
Practice Address - Fax:978-818-6355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-14
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM15814OtherMEDICARE
MA9773363Medicaid