Basic Information
| Provider Information | |||||||||
| NPI: | 1609887702 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAR OAKS ORTHOPEDISTS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6490 CENTERVILLE BUSINESS PKWY | ||||||||
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| City: | CENTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374335309 | ||||||||
| FaxNumber: | 9374331340 | ||||||||
| Practice Location | |||||||||
| Address1: | 2350 MIAMI VALLEY DR | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | CENTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374335309 | ||||||||
| FaxNumber: | 9374331340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 10/02/2008 | ||||||||
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| AuthorizedOfficialLastName: | KLEINHENZ | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | GENERAL PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9374335309 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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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 | 0379399 | 05 | OH | MEDICAID | DC5010 | 01 | OH | MEDICARE RAILROAD | OTHER | 2758494 | 05 | OH | MEDICAID |