Provider Demographics
NPI:1477746501
Name:STANISLAUS ORTHOPAEDICS SPORTS MEDICINE CLINIC
Entity Type:Organization
Organization Name:STANISLAUS ORTHOPAEDICS SPORTS MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:FIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-572-3224
Mailing Address - Street 1:609 E ORANGEBURG AVE
Mailing Address - Street 2:#201
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-5512
Mailing Address - Country:US
Mailing Address - Phone:209-572-3224
Mailing Address - Fax:209-572-4528
Practice Address - Street 1:609 E ORANGEBURG AVE
Practice Address - Street 2:#201
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5512
Practice Address - Country:US
Practice Address - Phone:209-572-3224
Practice Address - Fax:209-572-4528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty