Basic Information
| Provider Information | |||||||||
| NPI: | 1023330842 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ORTHOPEDIC SPECIALISTS OF NORTH AMERICA, PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OSNA - RUSSO DIVISION | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 271429 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841271429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027723800 | ||||||||
| FaxNumber: | 6027733801 | ||||||||
| Practice Location | |||||||||
| Address1: | 10290 N 92ND ST | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852584522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808601322 | ||||||||
| FaxNumber: | 4808604062 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2010 | ||||||||
| LastUpdateDate: | 11/30/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KINNA | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6027723790 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ORTHOPEDIC SPECIALISTS OF NORTH AMERICA, PLLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0106X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | DQ4501 | 01 | AZ | RAILROAD MEDICARE PTAN | OTHER |