MEDICARE: SPORT INSTITUTE OF TUCSON PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	3953	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11334734	OTHER	AZ	CAQH

General Provider Information

NPI Number	:	1154389005
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPORT INSTITUTE OF TUCSON PC

Provider Business Mailing Address
First Line	:	6369 E TANQUE VERDE RD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85715-3850
Country	:	US
Telephone Number	:	520-618-5500
Fax Number	:	520-618-5944

Provider Business Practice Location Address
First Line	:	6369 E TANQUE VERDE RD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85715-3850
Country	:	US
Telephone Number	:	520-618-5500
Fax Number	:	520-618-5944

Authorized Official
Title or Position	:	DIRECTOR/OWNER
Name	:	DR. TY HOWARD ENDEAN
Credential	:	D.O.
Telephone Number	:	520-618-5500

Provider Enumeration Date	:	05/02/2006
Last Update Date	:	08/27/2013

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Directions to “SPORT INSTITUTE OF TUCSON PC ” Practice Location

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