Provider Demographics
NPI:1396083937
Name:PRO SPORTS ORTHOPEDICS, INC
Entity type:Organization
Organization Name:PRO SPORTS ORTHOPEDICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SYSTEMS PROJECT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SURRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-491-6766
Mailing Address - Street 1:20 GUEST ST STE 225
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-2065
Mailing Address - Country:US
Mailing Address - Phone:617-738-8642
Mailing Address - Fax:617-202-4172
Practice Address - Street 1:20 GUEST ST STE 225
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-2065
Practice Address - Country:US
Practice Address - Phone:617-738-8642
Practice Address - Fax:617-202-4172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-16
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110070879AMedicaid
MA110070879AMedicaid
M14590Medicare PIN