Basic Information
| Provider Information | |||||||||
| NPI: | 1902281827 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OLYMPUS ORTHOPEDIC MEDICAL GROUP INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OLYMPUS ORTHOPEDICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3750 CONVOY ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921113738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583002260 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3750 CONVOY ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921113738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8582788300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2015 | ||||||||
| LastUpdateDate: | 11/20/2015 | ||||||||
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| AuthorizedOfficialLastName: | ANAKWENZE | ||||||||
| AuthorizedOfficialFirstName: | OKECHUKWU | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/SURGEON | ||||||||
| AuthorizedOfficialTelephone: | 8583002260 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | A126807 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
No ID Information.