Basic Information
| Provider Information | |||||||||
| NPI: | 1417060443 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPEDIC ASSOCIATES OF POTTSVILLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 510 | ||||||||
| Address2: | |||||||||
| City: | POTTSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 179010510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706225672 | ||||||||
| FaxNumber: | 5706226099 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 SCHUYLKILL MANOR RD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | POTTSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 179013849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706225672 | ||||||||
| FaxNumber: | 5706226099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 10/18/2007 | ||||||||
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| AuthorizedOfficialLastName: | STOUDT | ||||||||
| AuthorizedOfficialFirstName: | CALVIN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 5706225672 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | CF3054 | 01 | PA | TRAVELERS MEDICARE | OTHER | 074506 | 01 | HIGHMARK BS | OTHER |