Basic Information
| Provider Information | |||||||||
| NPI: | 1053712570 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PURDUE SPORTS MEDICINE WL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 STADIUM MALL DR | ||||||||
| Address2: | |||||||||
| City: | WEST LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479072052 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 JOHN R WOODEN DRIVE | ||||||||
| Address2: | MACKEY ARENA | ||||||||
| City: | WEST LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654943245 | ||||||||
| FaxNumber: | 7654949899 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2014 | ||||||||
| LastUpdateDate: | 10/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | VAUGHAN | ||||||||
| AuthorizedOfficialFirstName: | JOAN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | HIPAA PRIVACY OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7654961927 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RS0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sports Medicine | 2255A2300X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 2251X0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.