=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427485291
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROSEVILLE ORTHOPEDICS GROUP A MEDICAL CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2013
-----------------------------------------------------
Last Update Date | 10/10/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 151 N SUNRISE AVE STE 1005
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95661-2930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-782-1217
-----------------------------------------------------
Fax | 916-782-7630
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 151 N SUNRISE AVE STE 1005
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95661-2930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-782-1217
-----------------------------------------------------
Fax | 916-782-7630
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PA
-----------------------------------------------------
Name | BRIAN E ZERLAUT
-----------------------------------------------------
Credential | PA
-----------------------------------------------------
Telephone | 916-782-1217
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | PA19319
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------