Provider Demographics
NPI:1972694024
Name:ORTHOPEDIC MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:ORTHOPEDIC MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:HALSTEAD
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:574-282-1217
Mailing Address - Street 1:100 NAVARRE PL
Mailing Address - Street 2:SUITE 5500
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1156
Mailing Address - Country:US
Mailing Address - Phone:574-282-1217
Mailing Address - Fax:574-236-4884
Practice Address - Street 1:100 NAVARRE PL
Practice Address - Street 2:SUITE 5500
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1156
Practice Address - Country:US
Practice Address - Phone:574-282-1217
Practice Address - Fax:574-236-4884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
727100Medicare ID - Type Unspecified