Provider Demographics
NPI:1376966796
Name:SPECIALIZED ORTHOPEDIC SURGEONS INC.
Entity Type:Organization
Organization Name:SPECIALIZED ORTHOPEDIC SURGEONS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-624-8535
Mailing Address - Street 1:PO BOX 72798
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95617-2798
Mailing Address - Country:US
Mailing Address - Phone:707-624-7900
Mailing Address - Fax:
Practice Address - Street 1:1010 NUT TREE RD STE 200
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-4173
Practice Address - Country:US
Practice Address - Phone:707-624-7900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-22
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84728174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G847280Medicare UPIN