Provider Demographics
NPI:1245284751
Name:SOUTH COAST ORTHOPAEDIC ASSOCIATES, PC
Entity type:Organization
Organization Name:SOUTH COAST ORTHOPAEDIC ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:T
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-266-3600
Mailing Address - Street 1:2699 N 17TH ST
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2134
Mailing Address - Country:US
Mailing Address - Phone:541-266-3600
Mailing Address - Fax:541-269-0708
Practice Address - Street 1:2699 N 17TH ST
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2134
Practice Address - Country:US
Practice Address - Phone:541-266-3600
Practice Address - Fax:541-269-0708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 335E00000X
OR207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR076799Medicaid
OR0241940005Medicare NSC
OR076799Medicaid