Healthcare Provider Details

I. General information

NPI: 1316019193
Provider Name (Legal Business Name): ORTHOPAEDIC SPECIALISTS OF THE FOUR STATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 07/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 FOUR STATES DR SUITE 1
GALENA KS
66739-4324
US

IV. Provider business mailing address

PO BOX 2546
JOPLIN MO
64803-2546
US

V. Phone/Fax

Practice location:
  • Phone: 620-783-4441
  • Fax: 620-783-4185
Mailing address:
  • Phone: 620-783-4441
  • Fax: 620-783-4444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateKS
# 5
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateKS

VIII. Authorized Official

Name: JOSEPH M. CAPUTO
Title or Position: CHIEF ADMINISTRATIVE OFFICER
Credential:
Phone: 620-783-4441