Healthcare Provider Details

I. General information

NPI: 1316360068
Provider Name (Legal Business Name): PRIMARYCARE ORTHO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2014
Last Update Date: 09/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2625 W ALAMEDA AVE STE 116
BURBANK CA
91505-4815
US

IV. Provider business mailing address

2625 W ALAMEDA AVE STE 116 SUITE 116
BURBANK CA
91505-4815
US

V. Phone/Fax

Practice location:
  • Phone: 818-841-3936
  • Fax: 818-841-5974
Mailing address:
  • Phone: 818-841-3936
  • Fax: 818-841-5974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA66365
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License NumberA66365
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberA66365
License Number StateCA

VIII. Authorized Official

Name: DR. RAYMOND B. RAVEN III
Title or Position: DIRECTOR
Credential: MD, MBA
Phone: 818-841-3936