Provider Demographics
NPI:1912140583
Name:SOUTHWEST SPORTS MEDICINE & ORTHOPAEDIC SURGERY CLINIC, LTD.
Entity Type:Organization
Organization Name:SOUTHWEST SPORTS MEDICINE & ORTHOPAEDIC SURGERY CLINIC, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANGELO
Authorized Official - Middle Name:J
Authorized Official - Last Name:MATTALINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-860-2618
Mailing Address - Street 1:8129 N. 87TH PLACE
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258
Mailing Address - Country:US
Mailing Address - Phone:480-860-2618
Mailing Address - Fax:480-998-3879
Practice Address - Street 1:2730 SOUTH VAL VISTA
Practice Address - Street 2:STE. 117
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295
Practice Address - Country:US
Practice Address - Phone:480-763-5950
Practice Address - Fax:480-998-3879
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHWEST SPORTS MEDICINE & ORTHOPAEDIC SURGERY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-13
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3696207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0788930001Medicare NSC