Provider Demographics
NPI:1760551238
Name:ORTHOSOURCE MEDICAL CLINICS INC, DBA ORTHOCENTER MEDICAL GROUP INC
Entity Type:Organization
Organization Name:ORTHOSOURCE MEDICAL CLINICS INC, DBA ORTHOCENTER MEDICAL GROUP INC
Other - Org Name:ORTHOCENTER MEDICAL GROUP INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-449-0933
Mailing Address - Street 1:425 FAIR OAKS
Mailing Address - Street 2:SUITE A
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2632
Mailing Address - Country:US
Mailing Address - Phone:626-744-0434
Mailing Address - Fax:626-449-0934
Practice Address - Street 1:425 FAIR OAKS
Practice Address - Street 2:SUITE A
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2632
Practice Address - Country:US
Practice Address - Phone:626-744-0434
Practice Address - Fax:626-449-0934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG045078174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA49873Medicare UPIN