1275536484 NPI number — ALLIANCE ORTHOPEDIC LABS, LLC

Table of content: (NPI 1275536484)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275536484 NPI number — ALLIANCE ORTHOPEDIC LABS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALLIANCE ORTHOPEDIC LABS, LLC
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:
Provider Other Organization Name Type Code:
6
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:
1275536484
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17530 DUGDALE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46635-1583
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-233-3352
Provider Business Mailing Address Fax Number:
574-288-1514

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
134 HOLIDAY CT STE 302
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANNAPOLIS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-224-2000
Provider Business Practice Location Address Fax Number:
410-224-5696
Provider Enumeration Date:
05/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LADERER
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
574-233-3352

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  02991470 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 027147400 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 714501200 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009190139 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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