Basic Information
| Provider Information | |||||||||
| NPI: | 1083729438 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPEDIC SURGERY AND SPORTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 W IRONWOOD DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838144903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086642175 | ||||||||
| FaxNumber: | 2086641226 | ||||||||
| Practice Location | |||||||||
| Address1: | 850 W IRONWOOD DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838144903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086642175 | ||||||||
| FaxNumber: | 2086641226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 09/06/2017 | ||||||||
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| AuthorizedOfficialLastName: | DUNTEMAN | ||||||||
| AuthorizedOfficialFirstName: | ROGER | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 2086642175 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | N | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.