Healthcare Provider Details

I. General information

NPI: 1699920272
Provider Name (Legal Business Name): ACTIVE ATHLETE SPORTS MEDICINE PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2008
Last Update Date: 02/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3891 CHARLESTOWN RD
NEW ALBANY IN
47150-9562
US

IV. Provider business mailing address

3891 CHARLESTOWN ROAD
NEW ALBANY IN
47150
US

V. Phone/Fax

Practice location:
  • Phone: 812-949-3482
  • Fax: 812-812-9418
Mailing address:
  • Phone: 812-949-3482
  • Fax: 812-812-9418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number01033436A
License Number StateIN

VIII. Authorized Official

Name: MRS. TRICIA ROBERTS
Title or Position: MANAGER
Credential:
Phone: 812-949-3482