Provider Demographics
NPI:1972996098
Name:BOSTON SPORTS & SHOULDER CENTER, LLC
Entity type:Organization
Organization Name:BOSTON SPORTS & SHOULDER CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-890-2133
Mailing Address - Street 1:840 WINTER ST
Mailing Address - Street 2:ATTN: BOSTON SPORTS & SHOULDER CENTER
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02451-1433
Mailing Address - Country:US
Mailing Address - Phone:781-890-2133
Mailing Address - Fax:781-890-2177
Practice Address - Street 1:125 PARKER HILL AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02120-2847
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:2015-03-13
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty