Provider Demographics
NPI:1457341331
Name:PARKWAY ORTHOPEDICS & SPORTS MEDICINE
Entity Type:Organization
Organization Name:PARKWAY ORTHOPEDICS & SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SOARES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-679-9032
Mailing Address - Street 1:968 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-2314
Mailing Address - Country:US
Mailing Address - Phone:617-323-3334
Mailing Address - Fax:617-327-9330
Practice Address - Street 1:968 SOUTH ST
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131-2314
Practice Address - Country:US
Practice Address - Phone:617-323-3334
Practice Address - Fax:617-327-9330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA46262207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0157082Medicaid
MA1259840001Medicare NSC
MA0157082Medicaid
MAM14302Medicare PIN