Basic Information
| Provider Information | |||||||||
| NPI: | 1710983200 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ORTHOPEDIC SPECIALISTS & SPORTS MEDICINE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | ORTHOPEDIC SPECIALISTS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2750 NEWARK GRANVILLE RD | ||||||||
| Address2: | |||||||||
| City: | GRANVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430239142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407889220 | ||||||||
| FaxNumber: | 7407889226 | ||||||||
| Practice Location | |||||||||
| Address1: | 2750 NEWARK GRANVILLE RD | ||||||||
| Address2: | |||||||||
| City: | GRANVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430239142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407889220 | ||||||||
| FaxNumber: | 7407889226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2005 | ||||||||
| LastUpdateDate: | 04/13/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WESTERHEIDE | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7407889220 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 04/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 35047273 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.