Provider Demographics
NPI:1609471929
Name:ORTHO 1 MEDICAL GROUP
Entity Type:Organization
Organization Name:ORTHO 1 MEDICAL GROUP
Other - Org Name:ORTHO 1 MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ALMA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCLINTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-333-4847
Mailing Address - Street 1:9834 GENESEE AVE STE 228
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1215
Mailing Address - Country:US
Mailing Address - Phone:858-455-9942
Mailing Address - Fax:858-455-6473
Practice Address - Street 1:9834 GENESEE AVE STE 228
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1215
Practice Address - Country:US
Practice Address - Phone:858-455-9942
Practice Address - Fax:858-455-6473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-03
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8584559942OtherPHONE NUMBER