Provider Demographics
NPI:1245428069
Name:ORTHOPAEDIC MEDICAL GROUP
Entity Type:Organization
Organization Name:ORTHOPAEDIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:O
Authorized Official - Last Name:BRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-918-6655
Mailing Address - Street 1:PO BOX 490
Mailing Address - Street 2:
Mailing Address - City:DAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773
Mailing Address - Country:US
Mailing Address - Phone:909-971-9334
Mailing Address - Fax:
Practice Address - Street 1:14375 PIPELINE AVE
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710
Practice Address - Country:US
Practice Address - Phone:909-517-3884
Practice Address - Fax:909-517-3646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ20891ZMedicare PIN