Basic Information
| Provider Information | |||||||||
| NPI: | 1841682309 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MATTALINO ORTHOPAEDIC SPORTS SURGICAL SPECIALISTS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 E HIGHLAND AVE | ||||||||
| Address2: | SUITE 425 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850164872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026676640 | ||||||||
| FaxNumber: | 6026676625 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 E HIGHLAND AVE | ||||||||
| Address2: | SUITE 425 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850164872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026676640 | ||||||||
| FaxNumber: | 6026676625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2015 | ||||||||
| LastUpdateDate: | 02/20/2015 | ||||||||
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| AuthorizedOfficialLastName: | MATTALINO | ||||||||
| AuthorizedOfficialFirstName: | ANGELO | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6023215896 | ||||||||
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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 | 207XX0005X | 17728 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
No ID Information.