Provider Demographics
NPI:1720158488
Name:ADVANCED ORTHOPEDICS, A MEDICAL GROUP
Entity Type:Organization
Organization Name:ADVANCED ORTHOPEDICS, A MEDICAL GROUP
Other - Org Name:ADVANCED ORTHOPEDICS A SPORT MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PELTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-788-0101
Mailing Address - Street 1:PO BOX 260980
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91426
Mailing Address - Country:US
Mailing Address - Phone:818-788-0101
Mailing Address - Fax:818-788-0176
Practice Address - Street 1:16530 VENTURA BL
Practice Address - Street 2:SUITE 100
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436
Practice Address - Country:US
Practice Address - Phone:818-788-0101
Practice Address - Fax:818-788-0176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW11349Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER