Provider Demographics
NPI:1730426305
Name:INSTITUTE FOR COLLEGIATE SPORTS MEDICINE
Entity type:Organization
Organization Name:INSTITUTE FOR COLLEGIATE SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-204-5428
Mailing Address - Street 1:PO BOX 669582
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33066-9582
Mailing Address - Country:US
Mailing Address - Phone:954-204-5428
Mailing Address - Fax:
Practice Address - Street 1:3511 SAHARA SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33069-6101
Practice Address - Country:US
Practice Address - Phone:954-204-5428
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty