Provider Demographics
NPI:1417287970
Name:ATHELITE ORTHOPEDICS AND SPORTS MEDICINE, LLC
Entity Type:Organization
Organization Name:ATHELITE ORTHOPEDICS AND SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:FLORY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-822-2675
Mailing Address - Street 1:365 S PARK RIDGE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-8361
Mailing Address - Country:US
Mailing Address - Phone:812-822-2675
Mailing Address - Fax:812-822-2679
Practice Address - Street 1:365 S PARK RIDGE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-8361
Practice Address - Country:US
Practice Address - Phone:812-822-2675
Practice Address - Fax:812-822-2679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-06
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1052068207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200272920Medicaid
IN200272920Medicaid
G34814Medicare UPIN