NPIMap

Organization Active NPI

Indiana Sports & Medical Science Institute, PC

  • Clinic/Center
  • Crown Point, IN
National Provider Identifier
1609155290
Registry record updated Jul 11, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic/CenterTaxonomy code 261Q00000X
License
02003099A Issued in IN
Legal business name
INDIANA SPORTS & MEDICAL SCIENCE INSTITUTE, PC
Practice address
11275 Delaware Pkwy Ste a
Crown Point, IN 46307-7812
Phone
(219) 779-8735
Fax
(877) 715-2312
NPI assigned
Aug 12, 2011
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 11, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Timothy James Mullaly, DO
Title
Owner
Phone
(810) 814-2661

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X 02003099A IN Primary

Addresses

Primary practice location

11275 Delaware Pkwy Ste a
Crown Point, IN 46307-7812

Mailing address

PO Box 108
Crown Point, IN 46308-0108
Phone (219) 662-5530

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20110907001110 IN Part B Supplier - Clinic/Group Practice 2860662517 Receives reassigned benefits from 7 practitioners
Practice locations: Crown Point, IN

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
15D2029164Indiana Sports & Medical Science Institute, PC11275 Delaware Parkway, Crown Point, IN 46307Certificate of waiverAug 31, 2027

National Provider Directory

National Provider Directory

Locations

11275 Delaware Pkwy
#100
Crown Point, IN 46307

11275 Delaware Pkwy
Crown Point, IN 46307
Phone (219) 779-8735

11275 Delaware Pkwy
#A
Crown Point, IN 46307
Phone (219) 662-5530

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1313107200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1657497600000",
    "number": "1609155290",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 108",
            "city": "CROWN POINT",
            "state": "IN",
            "postal_code": "463080108",
            "telephone_number": "219-662-5530",
            "fax_number": "219-662-1365"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11275 DELAWARE PKWY STE A",
            "city": "CROWN POINT",
            "state": "IN",
            "postal_code": "463077812",
            "telephone_number": "219-779-8735",
            "fax_number": "877-715-2312"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INDIANA SPORTS & MEDICAL SCIENCE INSTITUTE, PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-08-12",
        "last_updated": "2022-07-11",
        "certification_date": "2022-07-11",
        "status": "A",
        "authorized_official_last_name": "MULLALY",
        "authorized_official_first_name": "TIMOTHY",
        "authorized_official_middle_name": "JAMES",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "810-814-2661",
        "authorized_official_credential": "DO"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "IN",
            "license": "02003099A",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Crown Point, IN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 11, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.