Provider Demographics
NPI:1154389005
Name:SPORT INSTITUTE OF TUCSON PC
Entity type:Organization
Organization Name:SPORT INSTITUTE OF TUCSON PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TY
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:ENDEAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:520-618-5500
Mailing Address - Street 1:6369 E TANQUE VERDE RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-3850
Mailing Address - Country:US
Mailing Address - Phone:520-618-5500
Mailing Address - Fax:520-618-5944
Practice Address - Street 1:6369 E TANQUE VERDE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-3850
Practice Address - Country:US
Practice Address - Phone:520-618-5500
Practice Address - Fax:520-618-5944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3953174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ11334734OtherCAQH
AZH70232Medicare UPIN
AZPENDINGMedicare ID - Type Unspecified