Provider Demographics
NPI:1912917840
Name:NEEDHAM ORTHOPEDIC AND SPORTS MEDICINE, LLC
Entity type:Organization
Organization Name:NEEDHAM ORTHOPEDIC AND SPORTS MEDICINE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:CORBETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-444-5080
Mailing Address - Street 1:300 CHESTNUT ST
Mailing Address - Street 2:SUITE 900
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02492-2497
Mailing Address - Country:US
Mailing Address - Phone:781-444-5080
Mailing Address - Fax:781-449-5026
Practice Address - Street 1:300 CHESTNUT ST
Practice Address - Street 2:SUITE 900
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02492-2497
Practice Address - Country:US
Practice Address - Phone:781-444-5080
Practice Address - Fax:781-449-5026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM19911OtherBLUE CROSS BLUE SHIELD OF MASSACHUSETTS
MA683459OtherTUFTS
MA9725661Medicaid
MAM19911OtherBLUE CROSS BLUE SHIELD OF MASSACHUSETTS
MA6386990001Medicare NSC
GROUPM21213Medicare PIN