Basic Information
| Provider Information | |||||||||
| NPI: | 1790768703 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPEDIC SURGERY ASSOC PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 WELLSPRING RD | ||||||||
| Address2: | |||||||||
| City: | BIDDEFORD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040059401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072831126 | ||||||||
| FaxNumber: | 2072861359 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 WELLSPRING RD | ||||||||
| Address2: | |||||||||
| City: | BIDDEFORD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040059401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072831126 | ||||||||
| FaxNumber: | 2072861359 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2005 | ||||||||
| LastUpdateDate: | 05/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | MARKELLOS | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 2072831126 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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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 | 115070000 | 05 | ME | MEDICAID | CE2135 | 01 | ME | RAILROAD MEDICARE | OTHER |