Provider Demographics
NPI:1154357739
Name:SPORTS MEDICINE INSTITUTE OF INDIANA, PC
Entity type:Organization
Organization Name:SPORTS MEDICINE INSTITUTE OF INDIANA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRANKLIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-841-8326
Mailing Address - Street 1:8040 CLEARVISTA PKWY
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-5630
Mailing Address - Country:US
Mailing Address - Phone:317-841-8326
Mailing Address - Fax:317-841-9195
Practice Address - Street 1:8040 CLEARVISTA PKWY
Practice Address - Street 2:SUITE 500
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-5630
Practice Address - Country:US
Practice Address - Phone:317-841-8326
Practice Address - Fax:317-841-9195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN339870Medicare ID - Type Unspecified