Healthcare Provider Details

I. General information

NPI: 1083729438
Provider Name (Legal Business Name): ORTHOPEDIC SURGERY AND SPORTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 05/20/2025
Certification Date: 05/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 W IRONWOOD DR STE 202
COEUR D ALENE ID
83814-4903
US

IV. Provider business mailing address

850 W IRONWOOD DR SUITE 202
COEUR D ALENE ID
83814-4903
US

V. Phone/Fax

Practice location:
  • Phone: 208-664-2175
  • Fax: 208-664-1226
Mailing address:
  • Phone: 208-664-2175
  • Fax: 208-664-1226

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 Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MR. ROGER C DUNTEMAN
Title or Position: OWNER/PARTNER
Credential: MD
Phone: 208-664-2175