Provider Demographics
NPI:1942602362
Name:CENTER FOR ORTHOPAEDIC SURGERY AND SPORTS MEDICINE
Entity Type:Organization
Organization Name:CENTER FOR ORTHOPAEDIC SURGERY AND SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PA
Authorized Official - Prefix:MS
Authorized Official - First Name:BETHANY
Authorized Official - Middle Name:A
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:317-888-1051
Mailing Address - Street 1:8141 S EMERSON AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-8560
Mailing Address - Country:US
Mailing Address - Phone:317-888-1051
Mailing Address - Fax:317-888-1591
Practice Address - Street 1:8141 S EMERSON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8560
Practice Address - Country:US
Practice Address - Phone:317-888-1051
Practice Address - Fax:317-888-1591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-17
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99063581A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN99063581AOtherLICENSE