Provider Demographics
NPI:1396182804
Name:THE PORRETTA CENTER FOR ORTHOPAEDIC SURGERY, PLLC
Entity Type:Organization
Organization Name:THE PORRETTA CENTER FOR ORTHOPAEDIC SURGERY, PLLC
Other - Org Name:THE CORE INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:O'HARA
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:866-974-2673
Mailing Address - Street 1:18444 N 25TH AVE
Mailing Address - Street 2:STE 310
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-1261
Mailing Address - Country:US
Mailing Address - Phone:866-974-2673
Mailing Address - Fax:866-939-2673
Practice Address - Street 1:22250 PROVIDENCE DR
Practice Address - Street 2:STE 401
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4825
Practice Address - Country:US
Practice Address - Phone:866-974-2673
Practice Address - Fax:866-939-2673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-24
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI332B00000X, 332BC3200X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0000000001Medicare NSC