1942571229 NPI number — OSTEOARTHRITIS CENTERS OF AMERICA MEDICAL GROUP PC

Table of content: (NPI 1942571229)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942571229 NPI number — OSTEOARTHRITIS CENTERS OF AMERICA MEDICAL GROUP PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OSTEOARTHRITIS CENTERS OF AMERICA MEDICAL GROUP PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
OSTEOARTHRITIS CENTERS OF AMERICA
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942571229
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14587 S 790 W
Provider Second Line Business Mailing Address:
SUITE A200
Provider Business Mailing Address City Name:
BLUFFDALE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84065-2319
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-478-2526
Provider Business Mailing Address Fax Number:
801-931-2498

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1097 N ROSARIO ST
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-8095
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-906-8322
Provider Business Practice Location Address Fax Number:
208-629-7059
Provider Enumeration Date:
01/19/2012

Additional Information

Authorized Official

Authorized Official Last Name:
CRAN
Authorized Official First Name:
CHRISTIAN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
801-258-1482

Provider Taxonomy Codes

  • Taxonomy code: 261QP3300X , with the licence number:  C190256 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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