Provider Demographics
NPI:1770802969
Name:PREMIER ORTHOPAEDIC AND SPORTS MEDICINE ASSOCIATES LTD
Entity type:Organization
Organization Name:PREMIER ORTHOPAEDIC AND SPORTS MEDICINE ASSOCIATES LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:STOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-359-5664
Mailing Address - Street 1:525 W CHESTER PIKE
Mailing Address - Street 2:STE 203
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-4500
Mailing Address - Country:US
Mailing Address - Phone:610-789-7767
Mailing Address - Fax:610-789-7768
Practice Address - Street 1:525 W CHESTER PIKE
Practice Address - Street 2:STE 203
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-4500
Practice Address - Country:US
Practice Address - Phone:610-789-7767
Practice Address - Fax:610-789-7768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-27
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD430669208100000X
PAOS009727L208100000X
332B00000X
PAMD070801L208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA034967Medicare PIN