Provider Demographics
NPI:1588824569
Name:SPORTS MEDICINE INSTITUTE INC
Entity Type:Organization
Organization Name:SPORTS MEDICINE INSTITUTE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:OAKESON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:602-938-9696
Mailing Address - Street 1:PO BOX 1149
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85380-1149
Mailing Address - Country:US
Mailing Address - Phone:602-938-9696
Mailing Address - Fax:602-789-0668
Practice Address - Street 1:5620 W THUNDERBIRD RD
Practice Address - Street 2:SUITE B-1
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-4636
Practice Address - Country:US
Practice Address - Phone:602-938-9696
Practice Address - Fax:602-789-0668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-12
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ29019Medicare PIN