Provider Demographics
NPI:1326189564
Name:ATHLETIC INSTITUTE OF MEDICINE LTD
Entity type:Organization
Organization Name:ATHLETIC INSTITUTE OF MEDICINE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-778-1400
Mailing Address - Street 1:9475 E IRONWOOD SQUARE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-4576
Mailing Address - Country:US
Mailing Address - Phone:480-778-1400
Mailing Address - Fax:480-778-1400
Practice Address - Street 1:9475 E IRONWOOD SQUARE DR STE 100
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4576
Practice Address - Country:US
Practice Address - Phone:480-778-1400
Practice Address - Fax:480-778-0400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ=========OtherTAX ID