Provider Demographics
NPI:1386862654
Name:NORTHPARK ORTHOPAEDICS, PA
Entity Type:Organization
Organization Name:NORTHPARK ORTHOPAEDICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:JACK
Authorized Official - Last Name:BANTA
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:214-987-3434
Mailing Address - Street 1:8220 WALNUT HILL LN
Mailing Address - Street 2:SUITE 608
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4427
Mailing Address - Country:US
Mailing Address - Phone:214-987-3434
Mailing Address - Fax:214-987-3799
Practice Address - Street 1:8220 WALNUT HILL LN
Practice Address - Street 2:SUITE 608
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4427
Practice Address - Country:US
Practice Address - Phone:214-987-3434
Practice Address - Fax:214-987-3799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0438207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCZ0012OtherRAILROAD MEDICARE
TX00N46FMedicare PIN
TXCZ0012OtherRAILROAD MEDICARE