Provider Demographics
NPI:1972934529
Name:BOSTON SPORTS MEDICINE AND RESEARCH INSTITUTE LLC
Entity type:Organization
Organization Name:BOSTON SPORTS MEDICINE AND RESEARCH INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:GILL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-264-1100
Mailing Address - Street 1:40 ALLIED DR
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-6146
Mailing Address - Country:US
Mailing Address - Phone:617-264-1100
Mailing Address - Fax:617-264-1101
Practice Address - Street 1:40 ALLIED DR
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-6146
Practice Address - Country:US
Practice Address - Phone:617-264-1100
Practice Address - Fax:617-264-1101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-09
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA152013174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA11060187/AMedicaid
NX1175Medicare PIN
G35001Medicare UPIN