Provider Demographics
NPI:1720075450
Name:SUPERIOR SPORTS MEDICINE LLC
Entity Type:Organization
Organization Name:SUPERIOR SPORTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:C
Authorized Official - Last Name:FEDERICO
Authorized Official - Suffix:
Authorized Official - Credentials:ORTHOTIC FITTER
Authorized Official - Phone:919-459-4135
Mailing Address - Street 1:PO BOX 880
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27512-0880
Mailing Address - Country:US
Mailing Address - Phone:919-459-4135
Mailing Address - Fax:919-882-1247
Practice Address - Street 1:175 TOWERVIEW COURT
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513
Practice Address - Country:US
Practice Address - Phone:919-459-4135
Practice Address - Fax:919-882-1247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-27
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000878433332B00000X
NC00811335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC4792500001Medicare ID - Type Unspecified
NC4792500001Medicare NSC