Provider Demographics
NPI:1780655803
Name:ORTHOPAEDICS EAST & SPORTS MEDICINE CENTER, INC.
Entity Type:Organization
Organization Name:ORTHOPAEDICS EAST & SPORTS MEDICINE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BROHAWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-757-2663
Mailing Address - Street 1:810 W H SMITH BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-3763
Mailing Address - Country:US
Mailing Address - Phone:252-757-2663
Mailing Address - Fax:252-317-0829
Practice Address - Street 1:810 W H SMITH BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-3763
Practice Address - Country:US
Practice Address - Phone:252-757-2663
Practice Address - Fax:252-317-0829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-27
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC690262UMedicaid
1274070001Medicare NSC
2329653Medicare PIN