1063727048 NPI number — STEPHEN F AUSTIN STATE UNIVERSITY SPORTS MEDICINE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063727048 NPI number — STEPHEN F AUSTIN STATE UNIVERSITY SPORTS MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEPHEN F AUSTIN STATE UNIVERSITY SPORTS MEDICINE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063727048
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1936 NORTH ST
Provider Second Line Business Mailing Address:
SFA SPORTS MEDICINE CLINIC
Provider Business Mailing Address City Name:
NACOGDOCHES
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75965-3940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-468-4550
Provider Business Mailing Address Fax Number:
936-468-4052

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1936 NORTH ST
Provider Second Line Business Practice Location Address:
SFA SPORTS MEDICINE CLINIC
Provider Business Practice Location Address City Name:
NACOGDOCHES
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75965-3940
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-468-4550
Provider Business Practice Location Address Fax Number:
936-468-4052
Provider Enumeration Date:
08/13/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
SANDY
Authorized Official Middle Name:
Authorized Official Title or Position:
ASST AD FOR SPORTS MEDICINE
Authorized Official Telephone Number:
936-468-4550

Provider Taxonomy Codes

  • Taxonomy code: 261QS1000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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