MEDICARE: INDIANA SPORTS & MEDICAL SCIENCE INSTITUTE, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center	02003099A	IN

General Provider Information

NPI Number	:	1609155290
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDIANA SPORTS & MEDICAL SCIENCE INSTITUTE, PC

Provider Business Mailing Address
First Line	:	PO BOX 108
Second Line	:
City	:	CROWN POINT
State	:	IN
Zip	:	46308-0108
Country	:	US
Telephone Number	:	219-662-5530
Fax Number	:	219-662-1365

Provider Business Practice Location Address
First Line	:	11275 DELAWARE PKWY STE A
Second Line	:
City	:	CROWN POINT
State	:	IN
Zip	:	46307-7812
Country	:	US
Telephone Number	:	219-779-8735
Fax Number	:	877-715-2312

Authorized Official
Title or Position	:	OWNER
Name	:	TIMOTHY JAMES MULLALY
Credential	:	DO
Telephone Number	:	810-814-2661

Provider Enumeration Date	:	08/12/2011
Last Update Date	:	07/11/2022

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