Provider Demographics
NPI:1861680720
Name:CHILDREN'S SPORTS MEDICINE FOUNDATION
Entity Type:Organization
Organization Name:CHILDREN'S SPORTS MEDICINE FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LYLE
Authorized Official - Middle Name:J
Authorized Official - Last Name:MICHELI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-355-5971
Mailing Address - Street 1:PO BOX 3694
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-3694
Mailing Address - Country:US
Mailing Address - Phone:508-946-1665
Mailing Address - Fax:508-947-1293
Practice Address - Street 1:319 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5728
Practice Address - Country:US
Practice Address - Phone:617-355-5971
Practice Address - Fax:617-730-0178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9782621Medicaid
MAM14628OtherBCBS
MAM14628OtherBCBS