=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649327750
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORTHOPAEDIC SPECIALISTS OF NORTH CAROLINA, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2007
-----------------------------------------------------
Last Update Date | 11/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11221 GALLERIA AVE STE 101
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27614-8137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-562-9410
-----------------------------------------------------
Fax | 919-562-9425
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1107
-----------------------------------------------------
City | WAKE FOREST
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27588
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-562-9410
-----------------------------------------------------
Fax | 919-562-2948
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | MARK WILLIAM GALLAND
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 919-562-9410
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XS0117X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery of the Spine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207XX0005X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------