Basic Information
| Provider Information | |||||||||
| NPI: | 1023063963 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPEDICS & SPORTS MEDICINE PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2213 GRAND AVE | ||||||||
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| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503125305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152373974 | ||||||||
| FaxNumber: | 5158832692 | ||||||||
| Practice Location | |||||||||
| Address1: | 1223 S GEAR AVE | ||||||||
| Address2: | EASTMAN PLAZA-SUITE 101 | ||||||||
| City: | WEST BURLINGTON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 526551682 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3197535352 | ||||||||
| FaxNumber: | 3197530462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 10/23/2007 | ||||||||
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| AuthorizedOfficialLastName: | PAUL | ||||||||
| AuthorizedOfficialFirstName: | MITCHELL | ||||||||
| AuthorizedOfficialMiddleName: | HOLIDAY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 3197535352 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | IA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207X00000X | IA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0493536 | 05 | IA | MEDICAID |