Healthcare Provider Details

I. General information

NPI: 1952863615
Provider Name (Legal Business Name): TRAVIS SMARELLI MBA, MS, ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 04/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MAIN ST
WHITELAND IN
46184-1550
US

IV. Provider business mailing address

300 MAIN ST
WHITELAND IN
46184-1550
US

V. Phone/Fax

Practice location:
  • Phone: 317-407-4449
  • Fax:
Mailing address:
  • Phone: 317-407-4449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number36001887A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: