Basic Information
Provider Information | |||||||||
NPI: | 1912404435 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THOMAS A BRADY SPORTS MEDICINE CTR | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FORTE SPORTS MEDICINE AND ORTHOPEDICS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10767 ILLINOIS ST STE 3000 | ||||||||
Address2: |   | ||||||||
City: | CARMEL | ||||||||
State: | IN | ||||||||
PostalCode: | 460328972 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3178171200 | ||||||||
FaxNumber: | 3178171220 | ||||||||
Practice Location | |||||||||
Address1: | 639 S WALKER ST STE E | ||||||||
Address2: |   | ||||||||
City: | BLOOMINGTON | ||||||||
State: | IN | ||||||||
PostalCode: | 474032124 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8123334000 | ||||||||
FaxNumber: | 8123330611 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/11/2018 | ||||||||
LastUpdateDate: | 03/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RITTER | ||||||||
AuthorizedOfficialFirstName: | MARK | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3178171200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 03/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 207XS0106X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207X00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
No ID Information.