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General NPI Number Information
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NPI Number | 1083750764
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Entity Type | Organization
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Legal Business Name | PTR SPORTS, A MEDICAL CORPORATION
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Dates
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Enumeration Date | 01/29/2007
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Last Update Date | 10/28/2008
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Provider Practice Location Address
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Address Line | 1825 CIVIC CENTER DR SUITE 25
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City | SANTA CLARA
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State | CA
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Zip | 95050-7301
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Country | US
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Telephone | 408-404-4700
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Fax | 408-404-4701
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Provider Business Mailing Address
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Address Line | 1825 CIVIC CENTER DR SUITE 25
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City | SANTA CLARA
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State | CA
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Zip | 95050-7301
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Country | US
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Telephone | 408-404-4700
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Fax | 408-404-4701
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Authorized Official
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Title or Position | PRESIDENT
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Name | JEFFREY G BLUE
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Credential | M.D.
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Telephone | 408-404-4700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QS0010X
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Taxonomy Name | Sports Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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