Provider Demographics
NPI:1336346063
Name:CAPE COD FAMILY PRACTICE & SPORTS MEDICINE, P.C.
Entity Type:Organization
Organization Name:CAPE COD FAMILY PRACTICE & SPORTS MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSYCHUK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-539-3353
Mailing Address - Street 1:PO BOX 595
Mailing Address - Street 2:
Mailing Address - City:MASHPEE
Mailing Address - State:MA
Mailing Address - Zip Code:02649-0595
Mailing Address - Country:US
Mailing Address - Phone:508-539-3353
Mailing Address - Fax:508-539-6848
Practice Address - Street 1:34 BATES RD
Practice Address - Street 2:SUITE 202
Practice Address - City:MASHPEE
Practice Address - State:MA
Practice Address - Zip Code:02649-3280
Practice Address - Country:US
Practice Address - Phone:508-539-3353
Practice Address - Fax:508-539-6848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA210923204C00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
M20987Medicare PIN