Basic Information
| Provider Information | |||||||||
| NPI: | 1346548633 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTER FOR ORTHOPEDIC RESEARCH AND EDUCATION, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE CORE INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3010 W AGUA FRIA FWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850273943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6234743498 | ||||||||
| FaxNumber: | 6234557120 | ||||||||
| Practice Location | |||||||||
| Address1: | 1820 W MARYLAND AVE | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850151740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235375600 | ||||||||
| FaxNumber: | 8669392673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2011 | ||||||||
| LastUpdateDate: | 07/16/2013 | ||||||||
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| AuthorizedOfficialLastName: | JACOFSKY | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 6235375600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BC3200X | AZ | N | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment | 332B00000X | AZ | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 341246 | 05 | AZ | MEDICAID |