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General NPI Number Information
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NPI Number | 1316360068
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Entity Type | Organization
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Legal Business Name | PRIMARYCARE ORTHO INC
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Dates
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Enumeration Date | 01/31/2014
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Last Update Date | 09/29/2015
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Provider Practice Location Address
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Address Line | 2625 W ALAMEDA AVE STE 116
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City | BURBANK
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State | CA
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Zip | 91505-4815
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Country | US
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Telephone | 818-841-3936
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Fax | 818-841-5974
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Provider Business Mailing Address
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Address Line | 2625 W ALAMEDA AVE STE 116 SUITE 116
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City | BURBANK
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State | CA
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Zip | 91505-4815
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Country | US
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Telephone | 818-841-3936
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Fax | 818-841-5974
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. RAYMOND B. RAVEN III
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Credential | MD, MBA
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Telephone | 818-841-3936
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207XS0106X
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Taxonomy Name | Orthopaedic Hand Surgery Physician
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License Number | A66365
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 207XX0005X
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Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
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License Number | A66365
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | A66365
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License Number State | CA
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