Basic Information
| Provider Information | |||||||||
| NPI: | 1881622520 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HUMBOLDT ORTHOPAEDIC MEDICAL ASSOCIATES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2826 HARRIS ST | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955034809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074438066 | ||||||||
| FaxNumber: | 7072683250 | ||||||||
| Practice Location | |||||||||
| Address1: | 2826 HARRIS ST | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955034809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074438066 | ||||||||
| FaxNumber: | 7072683250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 02/12/2009 | ||||||||
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| AuthorizedOfficialLastName: | ESSKEW | ||||||||
| AuthorizedOfficialFirstName: | ANGIE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 7072683232 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | GR0069130 | 05 | CA | MEDICAID |