=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184799298
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UPPER VALLEY ORTHOPEDICS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2006
-----------------------------------------------------
Last Update Date | 11/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 360 E MAIN ST
-----------------------------------------------------
City | REXBURG
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83440-2015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-356-9550
-----------------------------------------------------
Fax | 208-356-8023
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 360 E MAIN ST
-----------------------------------------------------
City | REXBURG
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83440-2015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-356-9550
-----------------------------------------------------
Fax | 208-356-8023
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MICHAEL J LARSON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 208-356-9550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | M5158
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------