Provider Demographics
NPI:1376035923
Name:ALTA ORTHOPAEDIC MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:ALTA ORTHOPAEDIC MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:W
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-936-9377
Mailing Address - Street 1:511 BATH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93101-3403
Mailing Address - Country:US
Mailing Address - Phone:805-563-3307
Mailing Address - Fax:805-563-3827
Practice Address - Street 1:2027 VILLAGE LN STE 101
Practice Address - Street 2:
Practice Address - City:SOLVANG
Practice Address - State:CA
Practice Address - Zip Code:93463-2271
Practice Address - Country:US
Practice Address - Phone:805-688-8821
Practice Address - Fax:805-962-2154
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALTA ORTHOPAEDIC MEDICAL GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty