Provider Demographics
NPI:1548672686
Name:TOWSON UNIVERSITY SPORTS MEDICINE
Entity type:Organization
Organization Name:TOWSON UNIVERSITY SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF SPORTS MEDICINE
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-704-3606
Mailing Address - Street 1:8000 YORK RD
Mailing Address - Street 2:FIELD HOUSE 101
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21252-0001
Mailing Address - Country:US
Mailing Address - Phone:410-704-2707
Mailing Address - Fax:410-704-2727
Practice Address - Street 1:8000 YORK RD
Practice Address - Street 2:FIELD HOUSE 101
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21252-0001
Practice Address - Country:US
Practice Address - Phone:410-704-2707
Practice Address - Fax:410-704-2727
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TOWSON UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-23
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD246452081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty