Healthcare Provider Details

I. General information

NPI: 1194164335
Provider Name (Legal Business Name): ORTHOPEDIC SPECIALISTS OF NORTH AMERICA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2013
Last Update Date: 04/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18700 N 64TH DR STE 105
GLENDALE AZ
85308-7110
US

IV. Provider business mailing address

PO BOX 29870
PHOENIX AZ
85038-9870
US

V. Phone/Fax

Practice location:
  • Phone: 800-483-0726
  • Fax: 800-483-0729
Mailing address:
  • Phone: 602-772-3800
  • Fax: 602-772-3801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number50782
License Number StateAZ

VIII. Authorized Official

Name: JOLIE SHARP
Title or Position: CFAO
Credential:
Phone: 602-772-3800