Provider Demographics
NPI:1609937911
Name:LAKE TAHOE ORTHOPAEDIC INSTITUTE, A WATSON-SWANSON PROFESSIONAL CORP
Entity Type:Organization
Organization Name:LAKE TAHOE ORTHOPAEDIC INSTITUTE, A WATSON-SWANSON PROFESSIONAL CORP
Other - Org Name:TAHOE ORTHOPEDICS AND SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:E
Authorized Official - Last Name:SWANSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:775-783-3065
Mailing Address - Street 1:2170 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-7026
Mailing Address - Country:US
Mailing Address - Phone:530-543-5659
Mailing Address - Fax:530-541-8723
Practice Address - Street 1:212 ELKS POINT RD STE 200
Practice Address - Street 2:
Practice Address - City:ZEPHYR COVE
Practice Address - State:NV
Practice Address - Zip Code:89448-8001
Practice Address - Country:US
Practice Address - Phone:775-589-8950
Practice Address - Fax:775-588-1299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV207X00000X, 207XS0106X, 207XX0005X, 208100000X, 2081S0010X, 225X00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2003106Medicaid
NV30981Medicare ID - Type Unspecified
NVA35318Medicare UPIN
NV30989Medicare ID - Type Unspecified
NVH71408Medicare UPIN
NV36820Medicare ID - Type Unspecified
NVA35610Medicare UPIN
NV2003284Medicaid
NV2013265Medicaid