Provider Demographics
NPI:1417066788
Name:ADVANCED ORTHOPAEDICS AND SPORTS MEDICINE, PC
Entity Type:Organization
Organization Name:ADVANCED ORTHOPAEDICS AND SPORTS MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:MATANKY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-426-1000
Mailing Address - Street 1:1760 E FLORENCE BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-4764
Mailing Address - Country:US
Mailing Address - Phone:520-426-1000
Mailing Address - Fax:520-426-1395
Practice Address - Street 1:1760 E FLORENCE BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-4764
Practice Address - Country:US
Practice Address - Phone:520-426-1000
Practice Address - Fax:520-426-1395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22110207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZCH9210OtherRR MEDICARE
AZF66298OtherMERCY HEALTH PLANS
AZ344579Medicaid
AZF00672Medicaid
AZ65301Medicare PIN