=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962490078
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LODI ORTHOPAEDIC MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2005
-----------------------------------------------------
Last Update Date | 04/25/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 924 S FAIRMONT AVE
-----------------------------------------------------
City | LODI
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95240-5119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-334-2590
-----------------------------------------------------
Fax | 209-334-0944
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 924 S FAIRMONT AVE
-----------------------------------------------------
City | LODI
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95240-5119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-334-2590
-----------------------------------------------------
Fax | 209-334-0944
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. THOMAS PETER MCKENZIE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 209-334-2590
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------