MEDICARE: SPINE AND SPORTS SPECIALITIES MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	207LP2900X	Pain Medicine (Anesthesiology) Physician
2	207X00000X	Orthopaedic Surgery Physician	CA
3	207XS0106X	Orthopaedic Hand Surgery Physician
4	207XS0114X	Adult Reconstructive Orthopaedic Surgery Physician
5	207XS0117X	Orthopaedic Surgery of the Spine Physician
6	207XX0004X	Orthopaedic Foot and Ankle Surgery Physician
7	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician
8	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician
9	208VP0014X	Interventional Pain Medicine Physician
10	261QR0200X	Radiology Clinic/Center
11	261QU0200X	Urgent Care Clinic/Center
12	207X00000X	Orthopaedic Surgery Physician

General Provider Information

NPI Number	:	1013306174
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPINE AND SPORTS SPECIALITIES MEDICAL GROUP

Provider Business Mailing Address
First Line	:	1120 W LA VETA AVE STE 300
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92868-4246
Country	:	US
Telephone Number	:	714-598-1745
Fax Number	:	714-941-9539

Provider Business Practice Location Address
First Line	:	1120 W. LA VETA AVENUE
Second Line	:	SUITE 300
City	:	ORANGE
State	:	CA
Zip	:	92868-4233
Country	:	US
Telephone Number	:	714-598-1745
Fax Number	:	714-941-9539

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	MS. CORINNE WALKER
Credential	:
Telephone Number	:	714-598-1745

Provider Enumeration Date	:	01/13/2015
Last Update Date	:	11/01/2024

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