Provider Demographics
NPI:1295044964
Name:ORTHOPEDIC SPECIALISTS OF NORTH AMERICA, PLLC
Entity Type:Organization
Organization Name:ORTHOPEDIC SPECIALISTS OF NORTH AMERICA, PLLC
Other - Org Name:OSNA - CANYON ORTHOPAEDIC SURGEONS DIVISION
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:VANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-772-3800
Mailing Address - Street 1:PO BOX 29870
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85038-9870
Mailing Address - Country:US
Mailing Address - Phone:602-772-3800
Mailing Address - Fax:
Practice Address - Street 1:6760 W THUNDERBIRD RD
Practice Address - Street 2:SUITE E110
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5048
Practice Address - Country:US
Practice Address - Phone:623-846-7614
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ORTHOPEDIC SPECIALISTS OF NORTH AMERICA, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-29
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ207X00000X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ6419820009Medicare NSC