Provider Demographics
NPI:1932255791
Name:COPPER STATE ORTHOPEDICS, LTD
Entity Type:Organization
Organization Name:COPPER STATE ORTHOPEDICS, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHAR
Authorized Official - Middle Name:L
Authorized Official - Last Name:MANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-262-2663
Mailing Address - Street 1:1002 E MCDOWELL RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2625
Mailing Address - Country:US
Mailing Address - Phone:602-262-2663
Mailing Address - Fax:602-258-3008
Practice Address - Street 1:1002 E MCDOWELL RD
Practice Address - Street 2:SUITE A
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2625
Practice Address - Country:US
Practice Address - Phone:602-262-2663
Practice Address - Fax:602-258-3008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2008-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22049207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ397621Medicaid
AZZ84078Medicare ID - Type Unspecified
AZ397621Medicaid
AZG74427Medicare UPIN