Provider Demographics
NPI:1679698310
Name:STATEN ISLAND ORTHOPEDICS & SPORTS MEDICINE P.C
Entity type:Organization
Organization Name:STATEN ISLAND ORTHOPEDICS & SPORTS MEDICINE P.C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:F
Authorized Official - Last Name:SHERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-351-6500
Mailing Address - Street 1:2052 RICHMOND ROA
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306
Mailing Address - Country:US
Mailing Address - Phone:718-351-6500
Mailing Address - Fax:718-351-7672
Practice Address - Street 1:2052 RICHMOND ROAD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306
Practice Address - Country:US
Practice Address - Phone:718-351-6500
Practice Address - Fax:718-351-7672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207X00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWEG671Medicare ID - Type Unspecified