Provider Demographics
NPI:1013300128
Name:OSBORNE ORTHOPEDIC GROUP, INC
Entity Type:Organization
Organization Name:OSBORNE ORTHOPEDIC GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TOMMY
Authorized Official - Middle Name:TAYLOR
Authorized Official - Last Name:OSBORNE
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:757-777-4110
Mailing Address - Street 1:1701 CHURCH ST STE A
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23504-2304
Mailing Address - Country:US
Mailing Address - Phone:757-548-7190
Mailing Address - Fax:757-548-7190
Practice Address - Street 1:1701 CHURCH ST STE A
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23504-2304
Practice Address - Country:US
Practice Address - Phone:757-548-7190
Practice Address - Fax:757-548-7190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-13
Last Update Date:2021-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0213001933332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
362091900OtherOWCP
VA1598768103Medicaid