Provider Demographics
NPI:1184652562
Name:VERDE VALLEY ORTHOPEDICS PC
Entity Type:Organization
Organization Name:VERDE VALLEY ORTHOPEDICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:WINFRED
Authorized Official - Last Name:WYLIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-634-1112
Mailing Address - Street 1:450 S WILLARD ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-6743
Mailing Address - Country:US
Mailing Address - Phone:928-634-1112
Mailing Address - Fax:928-634-1117
Practice Address - Street 1:450 S WILLARD ST
Practice Address - Street 2:SUITE 101
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-6743
Practice Address - Country:US
Practice Address - Phone:928-634-1112
Practice Address - Fax:928-634-1117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
73881Medicare ID - Type Unspecified