Provider Demographics
NPI:1609519784
Name:WOODWORTH, SAM (ACSM EP)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:WOODWORTH
Suffix:
Gender:M
Credentials:ACSM EP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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Mailing Address - Street 1:5136 N KENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-2620
Mailing Address - Country:US
Mailing Address - Phone:574-215-2734
Mailing Address - Fax:
Practice Address - Street 1:2160 W 86TH ST STE 101
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1908
Practice Address - Country:US
Practice Address - Phone:574-215-2734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN224Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise Physiologist