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NPI Code Detail

MEDICARE: ADA ORTHOPEDICS & SPORTS MEDICINE, PC

MEDICARE: ADA ORTHOPEDICS & SPORTS MEDICINE, PC
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
1207X00000XOrthopaedic Surgery Physician

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1DD1743OTHEROKRAILROAD MEDICARE

General Provider Information

NPI Number : 1427196773
Entity Type Code : Organization
Provider Name (Legal Business Name) : ADA ORTHOPEDICS & SPORTS MEDICINE, PC
Provider Business Mailing Address
First Line : 625 N MONTE VISTA ST
Second Line :
City : ADA
State : OK
Zip : 74820-4613
Country : US
Telephone Number : 580-332-4443
Fax Number : 580-332-4846
Provider Business Practice Location Address
First Line : 625 N MONTE VISTA ST
Second Line :
City : ADA
State : OK
Zip : 74820-4613
Country : US
Telephone Number : 580-332-4443
Fax Number : 580-332-4846
Authorized Official
Title or Position : SURGEON
Name : ROGER JOHN CHARBONEAU
Credential : D.O.
Telephone Number : 580-332-4443
Provider Enumeration Date : 02/01/2007
Last Update Date : 03/27/2008

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Directions to “ADA ORTHOPEDICS & SPORTS MEDICINE, PC ” Practice Location

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