Provider Demographics
NPI:1003988338
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:602-747-4000
Mailing Address - Fax:
Practice Address - Street 1:2222 E HIGHLAND AVE
Practice Address - Street 2:STE 300
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-4872
Practice Address - Country:US
Practice Address - Phone:602-277-6211
Practice Address - Fax:866-242-5309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ207X00000X
207XX0005X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ511031Medicaid
AZZWCJCVMedicare PIN