Provider Demographics
| NPI: | 1306818331 |
|---|---|
| Name: | THE PORRETTA CENTER FOR ORTHOPAEDIC SURGERY, PLLC |
| Entity type: | Organization |
| Organization Name: | THE PORRETTA CENTER FOR ORTHOPAEDIC SURGERY, PLLC |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | MANAGING PARTNER |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | DAVID |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | MARKEL |
| Authorized Official - Suffix: | III |
| Authorized Official - Credentials: | MD |
| Authorized Official - Phone: | 866-974-2673 |
| Mailing Address - Street 1: | 18444 N 25TH AVE |
| Mailing Address - Street 2: | STE 310 |
| Mailing Address - City: | PHOENIX |
| Mailing Address - State: | AZ |
| Mailing Address - Zip Code: | 85023-1261 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 866-974-2673 |
| Mailing Address - Fax: | 866-939-2673 |
| Practice Address - Street 1: | 26750 PROVIDENCE PKWY STE 200 |
| Practice Address - Street 2: | |
| Practice Address - City: | NOVI |
| Practice Address - State: | MI |
| Practice Address - Zip Code: | 48374-1212 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 866-974-2673 |
| Practice Address - Fax: | 866-939-2673 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-02-03 |
| Last Update Date: | 2023-12-14 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| MI | 207XP3100X, 207XS0114X, 207XS0117X, 207XX0005X, 207XX0801X, 213E00000X, 213ES0103X, 332B00000X, 363A00000X, 363AS0400X, 207X00000X | |
| 225100000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 207XP3100X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery | Group - Multi-Specialty |
| No | 207XS0114X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | Group - Multi-Specialty |
| No | 207XS0117X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | Group - Multi-Specialty |
| No | 207XX0005X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | Group - Multi-Specialty |
| No | 207XX0801X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | Group - Multi-Specialty |
| No | 213E00000X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Group - Multi-Specialty | |
| No | 213ES0103X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | Group - Multi-Specialty |
| No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
| No | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies | Group - Multi-Specialty | |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| 0F36278 | Medicare PIN | ||
| MI | 0572200001 | Medicare NSC |
