Provider Demographics
NPI:1699399709
Name:THE ORTHOPEDIC CLINIC ASSOCIATION, INC
Entity type:Organization
Organization Name:THE ORTHOPEDIC CLINIC ASSOCIATION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:LARAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-747-4000
Mailing Address - Street 1:2901 N CENTRAL AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18700 N 64TH DR STE 205
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7112
Practice Address - Country:US
Practice Address - Phone:602-536-7480
Practice Address - Fax:602-533-4167
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BANNER MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-06-04
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty