Provider Demographics
NPI:1811154305
Name:ORTHOPAEDIC AND SPORTS MEDICINE CENTER LLC
Entity type:Organization
Organization Name:ORTHOPAEDIC AND SPORTS MEDICINE CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:FAUST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-268-8862
Mailing Address - Street 1:108 FORBES ST
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-1502
Mailing Address - Country:US
Mailing Address - Phone:410-268-8862
Mailing Address - Fax:410-268-0380
Practice Address - Street 1:8638 VETERANS HWY
Practice Address - Street 2:1ST FLOOR
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-1422
Practice Address - Country:US
Practice Address - Phone:410-729-4878
Practice Address - Fax:410-729-4525
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ORTHOPAEDIC AND SPORTS MEDICINE CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-21
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA2505332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD412902400Medicaid
MD0863140003Medicare NSC