Provider Demographics
NPI:1780806240
Name:PROGRESSIVE SPORTS MEDICINE, PC
Entity type:Organization
Organization Name:PROGRESSIVE SPORTS MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRAVELEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-444-5406
Mailing Address - Street 1:404 MCFARLAN RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KENNETT SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19348-2479
Mailing Address - Country:US
Mailing Address - Phone:610-444-5406
Mailing Address - Fax:610-444-5907
Practice Address - Street 1:404 MCFARLAN RD
Practice Address - Street 2:SUITE 201
Practice Address - City:KENNETT SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19348-2479
Practice Address - Country:US
Practice Address - Phone:610-444-5406
Practice Address - Fax:610-444-5907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101967721-0001Medicaid
PADG5832Medicare PIN
PA110635Medicare PIN