1851365472 NPI number — FIDELITY ORTHOPEDIC INC

Table of content: (NPI 1851365472)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851365472 NPI number — FIDELITY ORTHOPEDIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIDELITY ORTHOPEDIC INC
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:
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:
1851365472
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8514 N. MAIN ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAYTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45415-1325
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-228-0682
Provider Business Mailing Address Fax Number:
937-228-8193

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7677 YANKEE ST
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
CENTERVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45459-3475
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-435-7041
Provider Business Practice Location Address Fax Number:
937-228-8193
Provider Enumeration Date:
02/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MURKA
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
937-228-0682

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; 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: 2307417 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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