Provider Demographics
NPI:1124163530
Name:ORTHOPEDIC AND SURGICAL SPECIALTY COMPANY, LLC
Entity type:Organization
Organization Name:ORTHOPEDIC AND SURGICAL SPECIALTY COMPANY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:BOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-567-0269
Mailing Address - Street 1:14201 DALLAS PKWY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-2916
Mailing Address - Country:US
Mailing Address - Phone:972-763-3859
Mailing Address - Fax:480-603-9107
Practice Address - Street 1:750 N 40TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-6486
Practice Address - Country:US
Practice Address - Phone:602-797-7700
Practice Address - Fax:602-797-7979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
282N00000X
AZSH3571284300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ882747Medicaid
AZ030112Medicare Oscar/Certification
AZ882747Medicaid