Provider Demographics
NPI:1063727048
Name:STEPHEN F AUSTIN STATE UNIVERSITY SPORTS MEDICINE
Entity type:Organization
Organization Name:STEPHEN F AUSTIN STATE UNIVERSITY SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST AD FOR SPORTS MEDICINE
Authorized Official - Prefix:
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:ATC
Authorized Official - Phone:936-468-4550
Mailing Address - Street 1:1936 NORTH ST
Mailing Address - Street 2:SFA SPORTS MEDICINE CLINIC
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-3940
Mailing Address - Country:US
Mailing Address - Phone:936-468-4550
Mailing Address - Fax:936-468-4052
Practice Address - Street 1:1936 NORTH ST
Practice Address - Street 2:SFA SPORTS MEDICINE CLINIC
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-3940
Practice Address - Country:US
Practice Address - Phone:936-468-4550
Practice Address - Fax:936-468-4052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health