Provider Demographics
NPI:1114034501
Name:CLARK COUNTY ORTHOPEDIC GROUP LLC
Entity Type:Organization
Organization Name:CLARK COUNTY ORTHOPEDIC GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE CLERK
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-636-0793
Mailing Address - Street 1:UNIT 134
Mailing Address - Street 2:3050 HWY 5 N
Mailing Address - City:THOMASVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36784-4325
Mailing Address - Country:US
Mailing Address - Phone:334-636-0793
Mailing Address - Fax:334-636-2280
Practice Address - Street 1:UNIT 134
Practice Address - Street 2:3050 HWY 5 N
Practice Address - City:THOMASVILLE
Practice Address - State:AL
Practice Address - Zip Code:36784-4325
Practice Address - Country:US
Practice Address - Phone:334-636-0793
Practice Address - Fax:334-636-2280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00003627207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALK772OtherMEDICARE GROUP NUMBER
ALK772OtherMEDICARE GROUP NUMBER
ALC75389Medicare UPIN