Provider Demographics
NPI:1972566594
Name:ORTHOPAEDIC ASSOCIATES OF MUSKEGON, PC
Entity Type:Organization
Organization Name:ORTHOPAEDIC ASSOCIATES OF MUSKEGON, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORAL
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-830-2729
Mailing Address - Street 1:1400 MERCY DR
Mailing Address - Street 2:STE 100
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1836
Mailing Address - Country:US
Mailing Address - Phone:231-733-1326
Mailing Address - Fax:231-830-2764
Practice Address - Street 1:1400 MERCY DR
Practice Address - Street 2:STE 100
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1836
Practice Address - Country:US
Practice Address - Phone:231-733-1326
Practice Address - Fax:231-830-2764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-07
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0N94170OtherMEDICARE GROUP PROVIDER #