Provider Demographics
NPI:1891856779
Name:ORTHOPAEDIC AND SPORTS MEDICINE SPECIALIST
Entity Type:Organization
Organization Name:ORTHOPAEDIC AND SPORTS MEDICINE SPECIALIST
Other - Org Name:ACTIVE ORTHOPAEDIC SUPPLIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OF CORP.
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:F
Authorized Official - Last Name:POPE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-443-9191
Mailing Address - Street 1:224 PECAN PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-3308
Mailing Address - Country:US
Mailing Address - Phone:318-427-7856
Mailing Address - Fax:318-443-5379
Practice Address - Street 1:224 PECAN PARK AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-3308
Practice Address - Country:US
Practice Address - Phone:318-427-7856
Practice Address - Fax:318-443-5379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA133936Medicaid
LA5151550001Medicare NSC