Provider Demographics
NPI:1932862133
Name:SPORT MEDICINE AND ORTHOPAEDIC CENTER INC
Entity type:Organization
Organization Name:SPORT MEDICINE AND ORTHOPAEDIC CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:RIANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSCITTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-842-7010
Mailing Address - Street 1:501 DISCOVERY DR
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-3843
Mailing Address - Country:US
Mailing Address - Phone:757-842-7010
Mailing Address - Fax:
Practice Address - Street 1:5801 HARBOUR VIEW BLVD STE 201
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-2657
Practice Address - Country:US
Practice Address - Phone:757-842-7010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-15
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies