Provider Demographics
NPI:1164616652
Name:ORTHOPEDIC SPECIALISTS OF SOUTHERN CALIFORNIA A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:ORTHOPEDIC SPECIALISTS OF SOUTHERN CALIFORNIA A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NISSANOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-451-2280
Mailing Address - Street 1:PO BOX 108822
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73101-8822
Mailing Address - Country:US
Mailing Address - Phone:858-451-2280
Mailing Address - Fax:858-451-2280
Practice Address - Street 1:2080 CENTURY PARK EAST
Practice Address - Street 2:SUITE 1111
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-2029
Practice Address - Country:US
Practice Address - Phone:858-451-2280
Practice Address - Fax:858-451-2280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYG82348CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVG82348Medicare UPIN