Basic Information
Provider Information | |||||||||
NPI: | 1689283970 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ORTHOPEDIC SPECIALISTS OF NORTH AMERICA PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ORTHOARIZONA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 80217 | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850600217 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6023852115 | ||||||||
FaxNumber: | 4804226551 | ||||||||
Practice Location | |||||||||
Address1: | 7225 W HARRISON ST | ||||||||
Address2: |   | ||||||||
City: | CHANDLER | ||||||||
State: | AZ | ||||||||
PostalCode: | 852261513 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4803064160 | ||||||||
FaxNumber: | 4803067274 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/23/2020 | ||||||||
LastUpdateDate: | 07/27/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WELLS | ||||||||
AuthorizedOfficialFirstName: | DAWN | ||||||||
AuthorizedOfficialMiddleName: | MARIE | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6023852115 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ORTHOPEDIC SPECIALISTS OF NORTH AMERICA PLLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/27/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 225100000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 261QM1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.