1417287970 NPI number — ATHELITE ORTHOPEDICS AND SPORTS MEDICINE, LLC

Table of content: (NPI 1417287970)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417287970 NPI number — ATHELITE ORTHOPEDICS AND SPORTS MEDICINE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ATHELITE ORTHOPEDICS AND SPORTS MEDICINE, LLC
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:
1417287970
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
365 S PARK RIDGE RD
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47401-8361
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-822-2675
Provider Business Mailing Address Fax Number:
812-822-2679

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
365 S PARK RIDGE RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47401-8361
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-822-2675
Provider Business Practice Location Address Fax Number:
812-822-2679
Provider Enumeration Date:
01/06/2010

Additional Information

Authorized Official

Authorized Official Last Name:
FLORY
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
812-822-2675

Provider Taxonomy Codes

  • Taxonomy code: 207XX0004X , with the licence number:  1052068 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200272920 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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