Healthcare Provider Details

I. General information

NPI: 1023089323
Provider Name (Legal Business Name): ORA ORTHOPEDICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 04/29/2024
Certification Date: 04/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 S OAKWOOD AVE STE 7B
GENESEO IL
61254-1990
US

IV. Provider business mailing address

520 VALLEY VIEW DR
MOLINE IL
61265-6194
US

V. Phone/Fax

Practice location:
  • Phone: 309-762-3621
  • Fax: 309-762-3690
Mailing address:
  • Phone: 309-762-3621
  • Fax: 309-762-3690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number060006850
License Number StateIL

VIII. Authorized Official

Name: KENNETH BROCKMAN
Title or Position: CEO
Credential:
Phone: 563-322-0971