Healthcare Provider Details

I. General information

NPI: 1811505415
Provider Name (Legal Business Name): ORTHOPEDIC SPECIALISTS OF NORTH AMERICA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2020
Last Update Date: 07/24/2020
Certification Date: 07/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12684 W GILA BEND HWY
CASA GRANDE AZ
85193-9298
US

IV. Provider business mailing address

PO BOX 80217
PHOENIX AZ
85060-0217
US

V. Phone/Fax

Practice location:
  • Phone: 480-306-4174
  • Fax:
Mailing address:
  • Phone: 602-385-2115
  • Fax: 480-422-6551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DAWN MARIE WELLS
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 602-385-2115