Provider Demographics
NPI:1295123453
Name:SPORTS INJURY MEDICAL GROUP
Entity type:Organization
Organization Name:SPORTS INJURY MEDICAL GROUP
Other - Org Name:<UNAVAIL>
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:STRADWICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-922-1614
Mailing Address - Street 1:5900 HOLLIS ST.
Mailing Address - Street 2:SUITE K
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 ST.
Practice Address - Street 2:SUITE K
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?:Yes
Parent Organization LBN:SPORTS INJURY MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-12-22
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E91893Medicare UPIN