MEDICARE: INSTITUTE FOR COLLEGIATE SPORTS MEDICINE

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1730426305
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INSTITUTE FOR COLLEGIATE SPORTS MEDICINE

Provider Business Mailing Address
First Line	:	PO BOX 669582
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33066-9582
Country	:	US
Telephone Number	:	954-204-5428
Fax Number	:

Provider Business Practice Location Address
First Line	:	3511 SAHARA SPRINGS BLVD
Second Line	:
City	:	POMPANO BEACH
State	:	FL
Zip	:	33069-6101
Country	:	US
Telephone Number	:	954-204-5428
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRIAN ANDERSON
Credential	:
Telephone Number	:	954-204-5428

Provider Enumeration Date	:	01/15/2013
Last Update Date	:	01/15/2013

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