MEDICARE: MR. JACK CHARLES PURDY MD

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	207X00000X	Orthopaedic Surgery Physician	00G313870	CA

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	:	1801872155
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JACK CHARLES PURDY MD

Provider Business Mailing Address
First Line	:	17337 TRAMONTO DR
Second Line	:	UNIT 210
City	:	PACIFIC PALISADES
State	:	CA
Zip	:	90272-3121
Country	:	US
Telephone Number	:	310-453-3533
Fax Number	:	310-828-8038

Provider Business Practice Location Address
First Line	:	17337 TRAMONTO DR
Second Line	:	UNIT 210
City	:	PACIFIC PALISADES
State	:	CA
Zip	:	90272-3121
Country	:	US
Telephone Number	:	310-453-3533
Fax Number	:	310-828-8038

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/19/2005
Last Update Date	:	08/25/2014

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