Healthcare Provider Details

I. General information

NPI: 1043032485
Provider Name (Legal Business Name): ORTHO SPORT & SPINE PHYSICIANS OF WASHINGTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17600 NE DELFEL RD
RIDGEFIELD WA
98642
US

IV. Provider business mailing address

5788 ROSWELL RD
ATLANTA GA
30328
US

V. Phone/Fax

Practice location:
  • Phone: 800-678-4611
  • Fax:
Mailing address:
  • Phone: 678-752-7246
  • Fax:

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 Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: FAITH BELTZHOOVER
Title or Position: RCM DIRECTOR
Credential:
Phone: 800-678-4611