Basic Information
Provider Information | |||||||||
NPI: | 1265755375 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ORTHOPEDIC SPECIALISTS OF NORTH AMERICA PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | OSNA ACTIVE ORTHOPEDIC DIVISION | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 271429 | ||||||||
Address2: |   | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841271429 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6027723800 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4566 E INVERNESS AVE | ||||||||
Address2: | SUITE 108 | ||||||||
City: | MESA | ||||||||
State: | AZ | ||||||||
PostalCode: | 852064633 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4808893988 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/03/2010 | ||||||||
LastUpdateDate: | 11/09/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRADWAY | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 4808606005 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ORTHOPEDIC SPECIALISTS OF NORTH AMERICA PLLC | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
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 |