MEDICARE: EAST VALLEY ORTHOPEDIC AND SPINE ASSOC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207XS0117X	Orthopaedic Surgery of the Spine Physician	3893	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073569182
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST VALLEY ORTHOPEDIC AND SPINE ASSOC

Provider Business Mailing Address
First Line	:	1492 S MILL AVE
Second Line	:	1492 S MILL AVE #212
City	:	TEMPE
State	:	AZ
Zip	:	85281-5664
Country	:	US
Telephone Number	:	480-449-3867
Fax Number	:	480-449-3868

Provider Business Practice Location Address
First Line	:	1492 S MILL AVE
Second Line	:	1492 S MILL AVE #212
City	:	TEMPE
State	:	AZ
Zip	:	85281-5652
Country	:	US
Telephone Number	:	480-449-3867
Fax Number	:	480-449-3868

Authorized Official
Title or Position	:	MANAGAER
Name	:	MS. KAREN A BLACK
Credential	:
Telephone Number	:	480-449-2401

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	08/22/2020

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Directions to “EAST VALLEY ORTHOPEDIC AND SPINE ASSOC ” Practice Location

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