Provider Demographics
NPI:1316360068
Name:PRIMARYCARE ORTHO INC
Entity Type:Organization
Organization Name:PRIMARYCARE ORTHO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:B
Authorized Official - Last Name:RAVEN
Authorized Official - Suffix:III
Authorized Official - Credentials:MD, MBA
Authorized Official - Phone:818-841-3936
Mailing Address - Street 1:2625 W ALAMEDA AVE STE 116
Mailing Address - Street 2:SUITE 116
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-4815
Mailing Address - Country:US
Mailing Address - Phone:818-841-3936
Mailing Address - Fax:818-841-5974
Practice Address - Street 1:2625 W ALAMEDA AVE STE 116
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4815
Practice Address - Country:US
Practice Address - Phone:818-841-3936
Practice Address - Fax:818-841-5974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-31
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66365207X00000X, 207XS0106X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7397530001Medicare NSC