Healthcare Provider Details

I. General information

NPI: 1649327750
Provider Name (Legal Business Name): ORTHOPAEDIC SPECIALISTS OF NORTH CAROLINA, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11221 GALLERIA AVE STE 101
RALEIGH NC
27614-8137
US

IV. Provider business mailing address

PO BOX 1107
WAKE FOREST NC
27588
US

V. Phone/Fax

Practice location:
  • Phone: 919-562-9410
  • Fax: 919-562-9425
Mailing address:
  • Phone: 919-562-9410
  • Fax: 919-562-2948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateNC

VIII. Authorized Official

Name: MARK WILLIAM GALLAND
Title or Position: SECRETARY
Credential: MD
Phone: 919-562-9410