Provider Demographics
NPI:1528243698
Name:UNIVERSITY ORTHOPAEDIC AND SPORTS MEDICINE CLINIC, PA
Entity type:Organization
Organization Name:UNIVERSITY ORTHOPAEDIC AND SPORTS MEDICINE CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIK
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-388-2663
Mailing Address - Street 1:301 SETON PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665-8003
Mailing Address - Country:US
Mailing Address - Phone:512-388-2663
Mailing Address - Fax:
Practice Address - Street 1:301 SETON PKWY STE 300
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665-8003
Practice Address - Country:US
Practice Address - Phone:512-388-2663
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7881207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA123555Medicare UPIN