Basic Information
| Provider Information | |||||||||
| NPI: | 1356546535 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CALIFORNIA ORTHOPEDICS & SPINE INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MT. TAM ORTHOPEDICS, A MEDICAL CENTER, INC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 18 BON AIR RD | ||||||||
| Address2: | |||||||||
| City: | LARKSPUR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949391123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4159275300 | ||||||||
| FaxNumber: | 4159275242 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 BON AIR RD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | LARKSPUR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4159275300 | ||||||||
| FaxNumber: | 4159275242 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2007 | ||||||||
| LastUpdateDate: | 10/01/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAILEY | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | ORTHOPEDIC SURGEON | ||||||||
| AuthorizedOfficialTelephone: | 4159275300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CALIFORNIA ORTHOPEDICS & SPINE INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist | 2251X0800X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 207X00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.