Provider Demographics
NPI:1477587335
Name:UNIVERSITY SPORTS MEDICINE PC
Entity Type:Organization
Organization Name:UNIVERSITY SPORTS MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:LESLIE
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-222-3384
Mailing Address - Street 1:15810 S 45TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-7695
Mailing Address - Country:US
Mailing Address - Phone:480-222-3384
Mailing Address - Fax:480-222-3422
Practice Address - Street 1:15810 S 45TH ST STE 101
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-7695
Practice Address - Country:US
Practice Address - Phone:480-222-3384
Practice Address - Fax:480-222-3422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22472207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZF67641Medicare UPIN
AZWMBTM02Medicare ID - Type Unspecified