1881810844 NPI number — OMEGA ORTHOPAEDICS, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881810844 NPI number — OMEGA ORTHOPAEDICS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OMEGA ORTHOPAEDICS, 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:
1881810844
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
203 S. CANDY LANE
Provider Second Line Business Mailing Address:
SUITE 4B
Provider Business Mailing Address City Name:
COTTONWOOD
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86326-8107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-634-0123
Provider Business Mailing Address Fax Number:
928-634-0123

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
203 S. CANDY LANE
Provider Second Line Business Practice Location Address:
SUITE 4B
Provider Business Practice Location Address City Name:
COTTONWOOD
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86326-8107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-634-0123
Provider Business Practice Location Address Fax Number:
928-634-0123
Provider Enumeration Date:
04/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PETERS
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
JOSEPH
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
928-634-0123

Provider Taxonomy Codes

  • Taxonomy code: 207XX0801X , with the licence number:  09582 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 203943 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: AZ0008170 . This is a "BCBSAZ" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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