=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730426305
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INSTITUTE FOR COLLEGIATE SPORTS MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2013
-----------------------------------------------------
Last Update Date | 01/15/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3511 SAHARA SPRINGS BLVD
-----------------------------------------------------
City | POMPANO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33069-6101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-204-5428
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 669582
-----------------------------------------------------
City | POMPANO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33066-9582
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-204-5428
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | BRIAN ANDERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-204-5428
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------