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General NPI Number Information
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NPI Number | 1033254099
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Entity Type | Organization
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Legal Business Name | ORTHOPAEDICS SPORTS & WORKERS MEDICAL GROUP INC
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Dates
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Enumeration Date | 02/20/2007
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Last Update Date | 03/30/2010
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Provider Practice Location Address
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Address Line | 621 S HAM LN STE A
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City | LODI
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State | CA
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Zip | 95242-3533
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Country | US
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Telephone | 209-368-7777
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Fax | 209-368-7778
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Provider Business Mailing Address
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Address Line | 621 S HAM LN STE A
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City | LODI
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State | CA
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Zip | 95242-3533
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Country | US
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Telephone | 209-368-7777
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Fax | 209-368-7778
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GARY ROYCE WISNER
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Credential | M.D.
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Telephone | 209-368-7777
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | A41236
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License Number State | CA
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