Provider Demographics
NPI:1063765436
Name:SPORTS & REGENERATIVE MEDICINE PC
Entity type:Organization
Organization Name:SPORTS & REGENERATIVE MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MANISH
Authorized Official - Middle Name:
Authorized Official - Last Name:MANNAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-660-2173
Mailing Address - Street 1:PO BOX 80158
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46280-0158
Mailing Address - Country:US
Mailing Address - Phone:317-660-2173
Mailing Address - Fax:317-660-2393
Practice Address - Street 1:12188B N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-4840
Practice Address - Country:US
Practice Address - Phone:317-660-2173
Practice Address - Fax:317-660-2393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-22
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062145A207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INPENDINGOtherPENDING