Basic Information
| Provider Information | |||||||||
| NPI: | 1548672686 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TOWSON UNIVERSITY SPORTS MEDICINE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 8000 YORK RD | ||||||||
| Address2: | FIELD HOUSE 101 | ||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212520001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107042707 | ||||||||
| FaxNumber: | 4107042727 | ||||||||
| Practice Location | |||||||||
| Address1: | 8000 YORK RD | ||||||||
| Address2: | FIELD HOUSE 101 | ||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212520001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107042707 | ||||||||
| FaxNumber: | 4107042727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2014 | ||||||||
| LastUpdateDate: | 06/15/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILDER | ||||||||
| AuthorizedOfficialFirstName: | NATHAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF SPORTS MEDICINE | ||||||||
| AuthorizedOfficialTelephone: | 4107043606 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TOWSON UNIVERSITY | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081S0010X | 24645 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine |
No ID Information.