Provider Demographics
NPI:1063423911
Name:ORTHOPEDIC ASSOCIATES OF DALLAS LLP
Entity type:Organization
Organization Name:ORTHOPEDIC ASSOCIATES OF DALLAS LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-823-7090
Mailing Address - Street 1:PO BOX 650500
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0500
Mailing Address - Country:US
Mailing Address - Phone:214-818-1288
Mailing Address - Fax:214-818-1470
Practice Address - Street 1:3900 JUNIUS ST
Practice Address - Street 2:SUITE 500
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1615
Practice Address - Country:US
Practice Address - Phone:214-823-7090
Practice Address - Fax:214-823-1644
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ORTHOPEDIC ASSOCIATES OF DALLAS LLP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-10
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207XS0106X, 207XS0114X, 207XS0117X, 207XX0004X, 207XX0005X, 207XX0801X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Single Specialty
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic SurgeryGroup - Single Specialty
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle SurgeryGroup - Single Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic TraumaGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00K730OtherBCBS
TX083558901Medicaid
TX0354520001Medicare NSC
TX083558901Medicaid
TX00K730Medicare PIN