Basic Information
| Provider Information | |||||||||
| NPI: | 1700982741 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPEDIC MEDICAL GROUP OF SAN DIEGO, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3750 CONVOY ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921113738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8582788300 | ||||||||
| FaxNumber: | 8582781708 | ||||||||
| Practice Location | |||||||||
| Address1: | 3750 CONVOY ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921113738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8582788300 | ||||||||
| FaxNumber: | 8582781708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 02/04/2014 | ||||||||
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| AuthorizedOfficialLastName: | SANTORE | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/CFO | ||||||||
| AuthorizedOfficialTelephone: | 8582788300 | ||||||||
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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 | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.