Provider Demographics
NPI:1497701767
Name:CALIFORNIA ORTHOPEDICS & SPINE INC
Entity Type:Organization
Organization Name:CALIFORNIA ORTHOPEDICS & SPINE INC
Other - Org Name:MT. TAM ORTHOPEDICS, A MEDICAL CENTER, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BOARD MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:H
Authorized Official - Last Name:BYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-927-5300
Mailing Address - Street 1:18 BON AIR RD
Mailing Address - Street 2:
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94939-1123
Mailing Address - Country:US
Mailing Address - Phone:415-927-5300
Mailing Address - Fax:415-927-5242
Practice Address - Street 1:18 BON AIR RD
Practice Address - Street 2:
Practice Address - City:LARKSPUR
Practice Address - State:CA
Practice Address - Zip Code:94939
Practice Address - Country:US
Practice Address - Phone:415-927-5300
Practice Address - Fax:415-927-5242
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CALIFORNIA ORTHOPEDICS & SPINE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-26
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X, 207X00000X, 2251X0800X
CAZZZ13645Z207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0712420001Medicare NSC