Healthcare Provider Details

I. General information

NPI: 1609519784
Provider Name (Legal Business Name): SAM WOODWORTH ACSM EP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2022
Last Update Date: 04/18/2022
Certification Date: 04/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 W 86TH ST STE 101
INDIANAPOLIS IN
46260-1908
US

IV. Provider business mailing address

5136 N KENWOOD AVE
INDIANAPOLIS IN
46208-2620
US

V. Phone/Fax

Practice location:
  • Phone: 574-215-2734
  • Fax:
Mailing address:
  • Phone: 574-215-2734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: