=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346373065
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HASTINGS ORTHOPEDIC CLINIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2007
-----------------------------------------------------
Last Update Date | 04/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 840 COOK RD
-----------------------------------------------------
City | HASTINGS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49058-9616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-945-9520
-----------------------------------------------------
Fax | 269-945-3368
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 840 COOK RD PO BOX 290
-----------------------------------------------------
City | HASTINGS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49058-9616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-945-9520
-----------------------------------------------------
Fax | 269-945-3368
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING SUPERVISOR
-----------------------------------------------------
Name | KELLY SHELLENBARGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 269-945-4966
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 5101012880
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 5101013049
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 4301035154
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------