Basic Information
| Provider Information | |||||||||
| NPI: | 1639576440 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE PORRETTA CENTER FOR ORTHOPAEDIC SURGERY, PLLC | ||||||||
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| OtherOrganizationName: | THE CORE INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18444 N 25TH AVE | ||||||||
| Address2: | STE 310 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850231266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669742673 | ||||||||
| FaxNumber: | 8669392673 | ||||||||
| Practice Location | |||||||||
| Address1: | 8273 GRAND RIVER RD | ||||||||
| Address2: | STE 210 | ||||||||
| City: | BRIGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481149346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669742673 | ||||||||
| FaxNumber: | 8669392673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2014 | ||||||||
| LastUpdateDate: | 07/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | MARKEL | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | MARKET PRESIDENT, MICHIGAN | ||||||||
| AuthorizedOfficialTelephone: | 8669742673 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 07/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335E00000X | MI | N | Suppliers | Prosthetic/Orthotic Supplier | 332BC3200X | MI | N | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment | 332B00000X | MI | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 000000 | 05 | MI | MEDICAID |