Basic Information
| Provider Information | |||||||||
| NPI: | 1588966170 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE CENTER FOR ORTHOPEDIC RESEARCH AND EDUCATION, INC. | ||||||||
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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: | 6235375600 | ||||||||
| FaxNumber: | 8669392673 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863011618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287760137 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2010 | ||||||||
| LastUpdateDate: | 12/02/2010 | ||||||||
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| AuthorizedOfficialLastName: | JACOFSKY | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6235375600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207X00000X | 33149 | AZ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | DD0900 | 01 | AZ | RR MEDICARE | OTHER | 341246 | 05 | AZ | MEDICAID |