Healthcare Provider Details

I. General information

NPI: 1063765436
Provider Name (Legal Business Name): SPORTS & REGENERATIVE MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2012
Last Update Date: 02/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12188B N MERIDIAN ST
CARMEL IN
46032-4840
US

IV. Provider business mailing address

PO BOX 80158
INDIANAPOLIS IN
46280-0158
US

V. Phone/Fax

Practice location:
  • Phone: 317-660-2173
  • Fax: 317-660-2393
Mailing address:
  • Phone: 317-660-2173
  • Fax: 317-660-2393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number01062145A
License Number StateIN

VIII. Authorized Official

Name: MANISH MANNAN
Title or Position: OWNER
Credential: MD
Phone: 317-660-2173