Provider Demographics
NPI:1750493979
Name:SHASTA ORTHOPEDICS & SPORTS MEDICINE A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SHASTA ORTHOPEDICS & SPORTS MEDICINE A MEDICAL CORPORATION
Other - Org Name:SHASTA ORTHOPAEDICS AND SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:E
Authorized Official - Last Name:SCHWARTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-246-2467
Mailing Address - Street 1:PO BOX 991950
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96099-1950
Mailing Address - Country:US
Mailing Address - Phone:530-246-2467
Mailing Address - Fax:530-242-9460
Practice Address - Street 1:1255 LIBERTY STREET
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0814
Practice Address - Country:US
Practice Address - Phone:530-246-2467
Practice Address - Fax:530-242-9460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X, 207X00000X, 207XS0106X, 207XX0005X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ44371ZMedicare PIN