Provider Demographics
NPI:1043583370
Name:BECKER ORTHOPEDICS
Entity Type:Organization
Organization Name:BECKER ORTHOPEDICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-949-3045
Mailing Address - Street 1:3501 HEALTH CENTER BLVD
Mailing Address - Street 2:SUITE 2440
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-8127
Mailing Address - Country:US
Mailing Address - Phone:239-949-3045
Mailing Address - Fax:239-949-3015
Practice Address - Street 1:3501 HEALTH CENTER BLVD
Practice Address - Street 2:SUITE 2440
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-8127
Practice Address - Country:US
Practice Address - Phone:239-949-3045
Practice Address - Fax:239-949-3015
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MINNEAPOLIS ORTHOPAEDICS, LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-02-16
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF11000003392261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFS976AMedicare PIN