Provider Demographics
NPI:1376603183
Name:THE SPORTS CLINIC ORTHOPAEDIC MEDICAL ASSOCIATES, INC.
Entity Type:Organization
Organization Name:THE SPORTS CLINIC ORTHOPAEDIC MEDICAL ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:MERRILL
Authorized Official - Last Name:NOTTAGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-581-7001
Mailing Address - Street 1:23961 CALLE DE LA MAGDALENA
Mailing Address - Street 2:STE 229
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3616
Mailing Address - Country:US
Mailing Address - Phone:949-581-7001
Mailing Address - Fax:949-581-8410
Practice Address - Street 1:23961 CALLE DE LA MAGDALENA
Practice Address - Street 2:STE 229
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3616
Practice Address - Country:US
Practice Address - Phone:949-581-7001
Practice Address - Fax:949-581-8410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29856207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ38138ZOtherBLUE SHIELD GRP #
CAW11567Medicare ID - Type UnspecifiedMEDICARE GROUP #
CA0632340001Medicare NSC