Provider Demographics
NPI:1023063963
Name:ORTHOPEDICS & SPORTS MEDICINE PLC
Entity type:Organization
Organization Name:ORTHOPEDICS & SPORTS MEDICINE PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:HOLIDAY
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:319-753-5352
Mailing Address - Street 1:2213 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-5305
Mailing Address - Country:US
Mailing Address - Phone:515-237-3974
Mailing Address - Fax:515-883-2692
Practice Address - Street 1:1223 S GEAR AVE
Practice Address - Street 2:EASTMAN PLAZA-SUITE 101
Practice Address - City:WEST BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52655-1682
Practice Address - Country:US
Practice Address - Phone:319-753-5352
Practice Address - Fax:319-753-0462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA363A00000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0493536Medicaid
IA0493536Medicaid