Provider Demographics
NPI:1609155290
Name:INDIANA SPORTS & MEDICAL SCIENCE INSTITUTE, PC
Entity Type:Organization
Organization Name:INDIANA SPORTS & MEDICAL SCIENCE INSTITUTE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MULLALY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:810-814-2661
Mailing Address - Street 1:PO BOX 108
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46308-0108
Mailing Address - Country:US
Mailing Address - Phone:219-662-5530
Mailing Address - Fax:219-662-1365
Practice Address - Street 1:11275 DELAWARE PKWY STE A
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-7812
Practice Address - Country:US
Practice Address - Phone:219-779-8735
Practice Address - Fax:877-715-2312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-12
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003099A261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM100053807Medicare PIN