Provider Demographics
NPI:1972773471
Name:ORTHOPAEDIC SURGERY MEDICAL GROUP
Entity type:Organization
Organization Name:ORTHOPAEDIC SURGERY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAGOSTINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-835-3031
Mailing Address - Street 1:1125 E 17TH ST STE E218
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-2218
Mailing Address - Country:US
Mailing Address - Phone:714-835-3031
Mailing Address - Fax:714-835-6546
Practice Address - Street 1:1125 E 17TH ST STE E218
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-2218
Practice Address - Country:US
Practice Address - Phone:714-835-3031
Practice Address - Fax:714-835-6546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW1760Medicare PIN