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General NPI Number Information
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NPI Number | 1912140583
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Entity Type | Organization
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Legal Business Name | SOUTHWEST SPORTS MEDICINE & ORTHOPAEDIC SURGERY CLINIC, LTD.
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Dates
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Enumeration Date | 04/13/2009
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Last Update Date | 02/10/2011
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Provider Practice Location Address
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Address Line | 2730 SOUTH VAL VISTA STE. 117
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City | GILBERT
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State | AZ
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Zip | 85295
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Country | US
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Telephone | 480-763-5950
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Fax | 480-998-3879
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Provider Business Mailing Address
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Address Line | 8129 N. 87TH PLACE
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City | SCOTTSDALE
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State | AZ
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Zip | 85258
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Country | US
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Telephone | 480-860-2618
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Fax | 480-998-3879
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Authorized Official
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Title or Position | OWNER
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Name | MR. ANGELO J. MATTALINO
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Credential | MD
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Telephone | 480-860-2618
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 3696
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License Number State | AZ
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