Provider Demographics
NPI:1700495892
Name:MODERN SPORTS MEDICINE LLC
Entity Type:Organization
Organization Name:MODERN SPORTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REVENUE
Authorized Official - Prefix:MRS
Authorized Official - First Name:HALEIGH
Authorized Official - Middle Name:
Authorized Official - Last Name:MERSHON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-878-4806
Mailing Address - Street 1:1840 E WARNER RD STE 121
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-3445
Mailing Address - Country:US
Mailing Address - Phone:480-878-4806
Mailing Address - Fax:480-840-1672
Practice Address - Street 1:14821 N DEL WEBB BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-2145
Practice Address - Country:US
Practice Address - Phone:480-878-4806
Practice Address - Fax:480-840-1672
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MODERN SPORTS MEDICINE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
No2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports MedicineGroup - Multi-Specialty