1962459990 NPI number — ROSEVILLE ORTHOPEDIC GROUP A MEDICAL CORP

Table of content: (NPI 1962459990)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962459990 NPI number — ROSEVILLE ORTHOPEDIC GROUP A MEDICAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROSEVILLE ORTHOPEDIC GROUP A MEDICAL CORP
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:
1962459990
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
151 N SUNRISE AVE
Provider Second Line Business Mailing Address:
STE 1005
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95661-2924
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-782-1217
Provider Business Mailing Address Fax Number:
916-782-7630

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
151 N SUNRISE AVE
Provider Second Line Business Practice Location Address:
STE 1005
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95661-2930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-782-1217
Provider Business Practice Location Address Fax Number:
916-782-7630
Provider Enumeration Date:
05/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BUTLER
Authorized Official First Name:
DEBORAH
Authorized Official Middle Name:
A
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
916-782-1217

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ZZZ71352Z . This is a "MEDI-CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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