Provider Demographics
NPI:1780910802
Name:SPORTS ORTHOPEDIC ADVANCED REHABILITATION, LLC
Entity type:Organization
Organization Name:SPORTS ORTHOPEDIC ADVANCED REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GURIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-223-3339
Mailing Address - Street 1:4660 SLATER RD STE 240
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-4047
Mailing Address - Country:US
Mailing Address - Phone:952-223-3339
Mailing Address - Fax:952-314-1401
Practice Address - Street 1:4660 SLATER RD STE 240
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122
Practice Address - Country:US
Practice Address - Phone:952-223-3339
Practice Address - Fax:952-314-1401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-23
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN39052208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC05426OtherMEDICARE PTAN
MN1780910802Medicaid
G44349Medicare UPIN