Basic Information
| Provider Information | |||||||||
| NPI: | 1831483767 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TAHOE ORTHOPEDICS AND SPORTS MEDICINE, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 EMERALD BAY RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH LAKE TAHOE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961506207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305435659 | ||||||||
| FaxNumber: | 5305418723 | ||||||||
| Practice Location | |||||||||
| Address1: | 1139 3RD ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH LAKE TAHOE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961503465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305413100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2011 | ||||||||
| LastUpdateDate: | 04/17/2020 | ||||||||
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| AuthorizedOfficialLastName: | RUPP | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5305413100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | G82106 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.