Provider Demographics
NPI:1780057513
Name:UNIVERSITY OF THE INCARNATE WORD
Entity type:Organization
Organization Name:UNIVERSITY OF THE INCARNATE WORD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE ATHLETIC DIR SPORT MED
Authorized Official - Prefix:
Authorized Official - First Name:BJ
Authorized Official - Middle Name:
Authorized Official - Last Name:LOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-283-6481
Mailing Address - Street 1:4301 BROADWAY ST # 288
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-6318
Mailing Address - Country:US
Mailing Address - Phone:210-283-6481
Mailing Address - Fax:210-634-1252
Practice Address - Street 1:4301 BROADWAY ST # 288
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-6318
Practice Address - Country:US
Practice Address - Phone:210-283-6481
Practice Address - Fax:210-634-1252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty