Provider Demographics
NPI:1699920272
Name:ACTIVE ATHLETE SPORTS MEDICINE PSC
Entity type:Organization
Organization Name:ACTIVE ATHLETE SPORTS MEDICINE PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-949-3482
Mailing Address - Street 1:3891 CHARLESTOWN ROAD
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150
Mailing Address - Country:US
Mailing Address - Phone:812-949-3482
Mailing Address - Fax:812-812-9418
Practice Address - Street 1:3891 CHARLESTOWN RD
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-9562
Practice Address - Country:US
Practice Address - Phone:812-949-3482
Practice Address - Fax:812-812-9418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-24
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033436A207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100327800Medicaid
IN100327800Medicaid