=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750409017
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ASSOCIATED ORTHOPEDICS & SPORTS MEDICINE, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2007
-----------------------------------------------------
Last Update Date | 11/30/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4031 W PLANO PKWY STE 100
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-5617
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-985-1072
-----------------------------------------------------
Fax | 972-964-3469
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4031 W PLANO PKWY SUITE 100
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-5619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-985-1072
-----------------------------------------------------
Fax | 972-964-3469
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | LIA PENNINGTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 469-326-8611
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------