MEDICARE: FRUITLAND ORTHOPEDIC CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician	MD13079	OR
2	207X00000X	Orthopaedic Surgery Physician	M-6608	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710975057
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRUITLAND ORTHOPEDIC CLINIC

Provider Business Mailing Address
First Line	:	1118 NW 16TH ST
Second Line	:	SUITE C
City	:	FRUITLAND
State	:	ID
Zip	:	83619-2271
Country	:	US
Telephone Number	:	208-452-2510
Fax Number	:	208-452-2513

Provider Business Practice Location Address
First Line	:	1118 NW 16TH ST
Second Line	:	SUITE C
City	:	FRUITLAND
State	:	ID
Zip	:	83619-2271
Country	:	US
Telephone Number	:	208-452-2510
Fax Number	:	208-452-2513

Authorized Official
Title or Position	:	OWNER
Name	:	JAN OLOF DAHLIN
Credential	:	M.D.
Telephone Number	:	208-452-2510

Provider Enumeration Date	:	10/11/2005
Last Update Date	:	08/22/2020

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Directions to “FRUITLAND ORTHOPEDIC CLINIC ” Practice Location

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