Provider Demographics
NPI:1225033715
Name:ORTHOPEDIC ASSOCIATES OF DULUTH, P.A.
Entity Type:Organization
Organization Name:ORTHOPEDIC ASSOCIATES OF DULUTH, P.A.
Other - Org Name:ORTHOPAEDIC ASSOCIATES OF DULUTH, P.A.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JUNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-625-1886
Mailing Address - Street 1:1000 E 1ST ST
Mailing Address - Street 2:STE 404
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2297
Mailing Address - Country:US
Mailing Address - Phone:218-722-9753
Mailing Address - Fax:218-722-6515
Practice Address - Street 1:1000 E 1ST ST
Practice Address - Street 2:STE 404
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2297
Practice Address - Country:US
Practice Address - Phone:218-722-9753
Practice Address - Fax:218-722-6515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000018080OtherMEDICARE WPS
MN78040OROtherBLUE CROSS
A001OtherTRICARE
MN177808100Medicaid
MN177808100Medicaid
MN=========000EOtherMEDICA MA
MN0253880001Medicare NSC