Basic Information
| Provider Information | |||||||||
| NPI: | 1114005352 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALPINE ORTHOPAEDIC MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2488 N. CALIFORNIA ST | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952045508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099483333 | ||||||||
| FaxNumber: | 2099483330 | ||||||||
| Practice Location | |||||||||
| Address1: | 2488 N. CALIFORNIA ST | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952045508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099483333 | ||||||||
| FaxNumber: | 2099483330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 08/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | MCCUNE | ||||||||
| AuthorizedOfficialFirstName: | ANNE | ||||||||
| AuthorizedOfficialMiddleName: | DUNN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 2099467139 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MS HSA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XP3100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery | 207XS0106X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XS0114X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | 207XS0117X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207XX0004X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | 207XX0005X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207XX0801X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 195690700 | 01 | USDL | OTHER | CGP159090 | 01 | CGP # | OTHER | ZZZ71793Z | 05 | CA | MEDICAID | 0368640001 | 01 | CA | DMERC SUPPLIER NUMBER | OTHER |