Basic Information
| Provider Information | |||||||||
| NPI: | 1730580499 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EAST TEXAS BABTIST UNIVERSITY | ||||||||
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| OtherOrganizationName: | ETBU SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5050 SPRING VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752443995 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005559073 | ||||||||
| FaxNumber: | 9723673452 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 TIGER DR | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756701412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9039232237 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2014 | ||||||||
| LastUpdateDate: | 09/11/2014 | ||||||||
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| AuthorizedOfficialLastName: | HOLIDAY | ||||||||
| AuthorizedOfficialFirstName: | MARCUS | ||||||||
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| AuthorizedOfficialTitleorPosition: | HEAD TRAINER FOR SPORTS MEDICINE | ||||||||
| AuthorizedOfficialTelephone: | 9039232237 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
No ID Information.