Provider Demographics
NPI:1225190820
Name:ARIZONA COLLEGE OF ORTHOPEDIC SURGEONS, PLLC
Entity Type:Organization
Organization Name:ARIZONA COLLEGE OF ORTHOPEDIC SURGEONS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIT
Authorized Official - Middle Name:C
Authorized Official - Last Name:MCCALLA
Authorized Official - Suffix:
Authorized Official - Credentials:DO, MBA
Authorized Official - Phone:602-424-0935
Mailing Address - Street 1:PO BOX 10610
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85318-0610
Mailing Address - Country:US
Mailing Address - Phone:602-424-0935
Mailing Address - Fax:602-938-4241
Practice Address - Street 1:10815 W MCDOWELL RD
Practice Address - Street 2:SUITE 303
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-5007
Practice Address - Country:US
Practice Address - Phone:602-424-0935
Practice Address - Fax:602-938-4241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3671207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ596009Medicaid
H44472Medicare UPIN
101248Medicare ID - Type Unspecified
AZ596009Medicaid