Provider Demographics
NPI:1386647527
Name:ORTHOPEDIC SURGERY CENTER OF OC LLC
Entity Type:Organization
Organization Name:ORTHOPEDIC SURGERY CENTER OF OC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-782-5038
Mailing Address - Street 1:22 CORPORATE PLAZA #150
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660
Mailing Address - Country:US
Mailing Address - Phone:949-515-0708
Mailing Address - Fax:949-515-4821
Practice Address - Street 1:22 CORPORATE PLAZA
Practice Address - Street 2:#150
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660
Practice Address - Country:US
Practice Address - Phone:949-515-0708
Practice Address - Fax:949-515-4821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA060000520261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA051445OtherBLUE CROSS
CAZZZ60061ZOtherBLUE SHIELD
CAS051445Medicare ID - Type UnspecifiedMEDICARE ID#