Provider Demographics
NPI:1568659589
Name:SPORTS INJURY MEDICAL GRP, INC
Entity Type:Organization
Organization Name:SPORTS INJURY MEDICAL GRP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:J
Authorized Official - Last Name:STRUDWICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-922-1614
Mailing Address - Street 1:5900 HOLLIS STREET #K
Mailing Address - Street 2:
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608
Mailing Address - Country:US
Mailing Address - Phone:510-922-1614
Mailing Address - Fax:510-922-8564
Practice Address - Street 1:5900 HOLLIS STREET #K
Practice Address - Street 2:
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608
Practice Address - Country:US
Practice Address - Phone:510-922-1614
Practice Address - Fax:510-922-8564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ27090ZOtherMEDICARE PTAN