Provider Demographics
NPI:1871105312
Name:417 SPORTS MEDICINE AND ORTHOPEDICS LLC
Entity type:Organization
Organization Name:417 SPORTS MEDICINE AND ORTHOPEDICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:GIFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-825-5096
Mailing Address - Street 1:2100 E NORSHIRE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-7829
Mailing Address - Country:US
Mailing Address - Phone:817-825-5096
Mailing Address - Fax:
Practice Address - Street 1:3328 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7305
Practice Address - Country:US
Practice Address - Phone:417-771-3147
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-17
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
7860260001OtherNATIONAL SUPPLIER CLEARING HOUSE