Basic Information
| Provider Information | |||||||||
| NPI: | 1407428584 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE PORRETTA CENTER FOR ORTHOPAEDIC SURGERY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18444 N 25TH AVE STE 310 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850231266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669742673 | ||||||||
| FaxNumber: | 8669392673 | ||||||||
| Practice Location | |||||||||
| Address1: | 524 BYRON RD | ||||||||
| Address2: | |||||||||
| City: | HOWELL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488431410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669742673 | ||||||||
| FaxNumber: | 8669392673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2021 | ||||||||
| LastUpdateDate: | 07/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | MARKEL | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | MARKET PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6232418622 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE PORRETTA CENTER FOR ORTHOPAEDIC SURGERY, PLLC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 07/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 335E00000X | N | Suppliers | Prosthetic/Orthotic Supplier | 332BC3200X | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment |
No ID Information.