Provider Demographics
NPI:1083729438
Name:ORTHOPEDIC SURGERY AND SPORTS
Entity Type:Organization
Organization Name:ORTHOPEDIC SURGERY AND SPORTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:C
Authorized Official - Last Name:DUNTEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-664-2175
Mailing Address - Street 1:850 W IRONWOOD DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4903
Mailing Address - Country:US
Mailing Address - Phone:208-664-2175
Mailing Address - Fax:208-664-1226
Practice Address - Street 1:850 W IRONWOOD DR
Practice Address - Street 2:SUITE 202
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4903
Practice Address - Country:US
Practice Address - Phone:208-664-2175
Practice Address - Fax:208-664-1226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1374148Medicare PIN
ID4639120002Medicare NSC