Basic Information
| Provider Information | |||||||||
| NPI: | 1477587335 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY SPORTS MEDICINE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15810 S 45TH ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850487695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802223384 | ||||||||
| FaxNumber: | 4802223422 | ||||||||
| Practice Location | |||||||||
| Address1: | 15810 S 45TH ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850487695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802223384 | ||||||||
| FaxNumber: | 4802223422 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 08/23/2007 | ||||||||
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| AuthorizedOfficialLastName: | MCCOY | ||||||||
| AuthorizedOfficialFirstName: | ROGER | ||||||||
| AuthorizedOfficialMiddleName: | LESLIE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4802223384 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 22472 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.