=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629095492
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAGNUS ORTHOPAEDIC CLINIC, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2006
-----------------------------------------------------
Last Update Date | 06/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 865 LINCOLN RD SUITE 500A
-----------------------------------------------------
City | BETTENDORF
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52722-4190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-441-0101
-----------------------------------------------------
Fax | 563-441-9090
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 865 LINCOLN RD SUITE 500A
-----------------------------------------------------
City | BETTENDORF
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52722-4190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-441-0101
-----------------------------------------------------
Fax | 563-441-9090
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ROBERT E MAGNUS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 563-441-0101
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 28680
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------