Provider Demographics
NPI:1215239934
Name:AASU SPORTS MEDICNE
Entity type:Organization
Organization Name:AASU SPORTS MEDICNE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEAD ATHLETIC TRAINER
Authorized Official - Prefix:MS
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:ATC
Authorized Official - Phone:912-414-0271
Mailing Address - Street 1:11935 ABERCORN ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-1909
Mailing Address - Country:US
Mailing Address - Phone:912-344-2866
Mailing Address - Fax:912-344-3420
Practice Address - Street 1:11935 ABERCORN ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-1909
Practice Address - Country:US
Practice Address - Phone:912-344-2866
Practice Address - Fax:912-344-3420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-01
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health