Basic Information
| Provider Information | |||||||||
| NPI: | 1043553092 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPAEDIC SPECIALTY CENTER | ||||||||
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| OtherOrganizationName: | ORTHOMARYLAND | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1312 BELLONA AVENUE | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | LUTHERVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210935436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103778900 | ||||||||
| FaxNumber: | 4103770576 | ||||||||
| Practice Location | |||||||||
| Address1: | 2700 QUARRY LAKE DRIVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212093746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103778900 | ||||||||
| FaxNumber: | 4103770576 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2013 | ||||||||
| LastUpdateDate: | 06/06/2014 | ||||||||
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| AuthorizedOfficialLastName: | BELL | ||||||||
| AuthorizedOfficialFirstName: | HEIDI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4103778900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ORTHOPAEDIC SPECIALTY CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 911351700 | 05 | MD | MEDICAID |