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General NPI Number Information
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NPI Number | 1609155290
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Entity Type | Organization
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Legal Business Name | INDIANA SPORTS & MEDICAL SCIENCE INSTITUTE, PC
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Dates
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Enumeration Date | 08/12/2011
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Last Update Date | 07/11/2022
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Provider Practice Location Address
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Address Line | 11275 DELAWARE PKWY STE A
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City | CROWN POINT
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State | IN
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Zip | 46307-7812
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Country | US
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Telephone | 219-779-8735
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Fax | 877-715-2312
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Provider Business Mailing Address
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Address Line | PO BOX 108
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City | CROWN POINT
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State | IN
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Zip | 46308-0108
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Country | US
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Telephone | 219-662-5530
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Fax | 219-662-1365
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Authorized Official
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Title or Position | OWNER
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Name | TIMOTHY JAMES MULLALY
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Credential | DO
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Telephone | 810-814-2661
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 02003099A
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License Number State | IN
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