Healthcare Provider Details

I. General information

NPI: 1548672686
Provider Name (Legal Business Name): TOWSON UNIVERSITY SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2014
Last Update Date: 06/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8000 YORK RD FIELD HOUSE 101
TOWSON MD
21252-0001
US

IV. Provider business mailing address

8000 YORK RD FIELD HOUSE 101
TOWSON MD
21252-0001
US

V. Phone/Fax

Practice location:
  • Phone: 410-704-2707
  • Fax: 410-704-2727
Mailing address:
  • Phone: 410-704-2707
  • Fax: 410-704-2727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number24645
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: NATHAN WILDER
Title or Position: DIRECTOR OF SPORTS MEDICINE
Credential:
Phone: 410-704-3606