Provider Demographics
NPI:1548225402
Name:WESTERN ORTHOPAEDIC & SPORTS MEDICINE CONSULTANTS, P.A.
Entity Type:Organization
Organization Name:WESTERN ORTHOPAEDIC & SPORTS MEDICINE CONSULTANTS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:D
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:ROTENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-442-6525
Mailing Address - Street 1:7261 OHMS LN
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439-2148
Mailing Address - Country:US
Mailing Address - Phone:952-442-6525
Mailing Address - Fax:952-442-6526
Practice Address - Street 1:490 S MAPLE ST
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1760
Practice Address - Country:US
Practice Address - Phone:952-442-6525
Practice Address - Fax:952-442-6526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1464174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC02865Medicare ID - Type Unspecified