Basic Information
| Provider Information | |||||||||
| NPI: | 1962481861 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORA ORTHOPEDICS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 VALLEY VIEW DR | ||||||||
| Address2: | |||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612656194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097623621 | ||||||||
| FaxNumber: | 3097623690 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 VALLEY VIEW DR | ||||||||
| Address2: | |||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612656194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097623621 | ||||||||
| FaxNumber: | 3097623690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 08/24/2012 | ||||||||
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| AuthorizedOfficialLastName: | BROCKMAN | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3097623621 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ORA ORTHOPEDICS PC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WM0705X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Medical-Surgical | 207QS0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207RR0500X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207XS0106X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 2084N0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0600X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 213ES0103X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 246ZS0410X | N | 193200000X MULTI-SPECIALTY GROUP | 247200000X | N | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Technician, Other | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 335E00000X | N | Suppliers | Prosthetic/Orthotic Supplier | 363AM0700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207X00000X | 060006850 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 58091 | 01 | IA | WELLMARK | OTHER | 58109 | 01 | IA | WELLMARK | OTHER | 92231 | 01 | IA | WELLMARK | OTHER | CN0248 | 01 | ID | RR MEDICARE | OTHER | 58104 | 01 | IA | WELLMARK | OTHER | 57821 | 01 | IA | WELLMARK | OTHER | 99204 | 01 | IA | WELLMARK | OTHER | 0073734 | 05 | IA | MEDICAID | CD9661 | 01 | IA | RR MEDICARE | OTHER | 37772 | 01 | IA | WELLMARK | OTHER | 8121085 | 01 | IL | BCBS-IL | OTHER | 91376 | 01 | IA | WELLMARK | OTHER |