Provider Demographics
NPI:1568072387
Name:MODERN SPORTS MEDICINE LLC
Entity Type:Organization
Organization Name:MODERN SPORTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REVENUE
Authorized Official - Prefix:MRS
Authorized Official - First Name:HALEIGH
Authorized Official - Middle Name:SHEREE
Authorized Official - Last Name:MERSHON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-878-4806
Mailing Address - Street 1:1840 E WARNER RD STE 121
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-3445
Mailing Address - Country:US
Mailing Address - Phone:480-878-4806
Mailing Address - Fax:480-840-1672
Practice Address - Street 1:1840 E WARNER RD STE 121
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-3445
Practice Address - Country:US
Practice Address - Phone:480-878-4806
Practice Address - Fax:480-840-1672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty