Healthcare Provider Details

I. General information

NPI: 1487687950
Provider Name (Legal Business Name): ORTHOPAEDIC TRAUMA ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 N COFCO CENTER CT SUITE 290
PHOENIX AZ
85008-6474
US

IV. Provider business mailing address

690 N COFCO CENTER CT SUITE 290
PHOENIX AZ
85008-6474
US

V. Phone/Fax

Practice location:
  • Phone: 602-256-7409
  • Fax: 602-258-5477
Mailing address:
  • Phone: 602-256-7409
  • Fax: 602-258-5477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number22789
License Number StateAZ

VIII. Authorized Official

Name: ROBERT A BERGHOFF
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 602-256-7409