MEDICARE: ORTHOPEDIC SPECIALISTS OF SOUTHERN CALIFORNIA A MEDICAL CORPORATION

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	174400000X	Specialist	G82348CA	NY

General Provider Information

NPI Number	:	1164616652
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORTHOPEDIC SPECIALISTS OF SOUTHERN CALIFORNIA A MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	PO BOX 108822
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73101-8822
Country	:	US
Telephone Number	:	858-451-2280
Fax Number	:	858-451-2280

Provider Business Practice Location Address
First Line	:	2080 CENTURY PARK EAST
Second Line	:	SUITE 1111
City	:	LOS ANGELES
State	:	CA
Zip	:	90067-2029
Country	:	US
Telephone Number	:	858-451-2280
Fax Number	:	858-451-2280

Authorized Official
Title or Position	:	MEDICAL DOCTOR
Name	:	DR. JONATHAN NISSANOFF
Credential	:	M.D.
Telephone Number	:	858-451-2280

Provider Enumeration Date	:	08/28/2007
Last Update Date	:	09/07/2016

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