Provider Demographics
NPI:1477807121
Name:STEPHEN F. AUSTIN STATE UNIVERSITY
Entity Type:Organization
Organization Name:STEPHEN F. AUSTIN STATE UNIVERSITY
Other - Org Name:STEPHEN F. AUSTIN STATE UNIVERSITY SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BAKER
Authorized Official - Middle Name:
Authorized Official - Last Name:PATILLO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:936-468-2201
Mailing Address - Street 1:712 HAYTER
Mailing Address - Street 2:PO BOX 13010 SFA STATION
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75962-3940
Mailing Address - Country:US
Mailing Address - Phone:936-468-3506
Mailing Address - Fax:936-468-4580
Practice Address - Street 1:712 HAYTER
Practice Address - Street 2:13010 SFA STATION
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75962-3940
Practice Address - Country:US
Practice Address - Phone:936-468-3506
Practice Address - Fax:936-468-4580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-02
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health