Healthcare Provider Details

I. General information

NPI: 1972929297
Provider Name (Legal Business Name): ORTHOCAROLINA, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2014
Last Update Date: 12/18/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3311 JESSIE VILLAGE DRIVE
CLEMMONS NC
27012
US

IV. Provider business mailing address

PO BOX 117444
ATLANTA GA
30368-7444
US

V. Phone/Fax

Practice location:
  • Phone: 336-659-4135
  • Fax: 336-794-3598
Mailing address:
  • Phone: 704-323-2250
  • Fax: 704-945-7679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number38865
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number38865
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number38865
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number38865
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number38865
License Number StateNC
# 6
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number38865
License Number StateNC
# 7
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number38865
License Number StateNC
# 8
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number38865
License Number StateNC
# 9
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number38865
License Number StateNC
# 10
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number38865
License Number StateNC

VIII. Authorized Official

Name: MR. BRENT SHEAR
Title or Position: CFO
Credential:
Phone: 704-323-2222