Provider Demographics
NPI:1932432457
Name:CAPITAL ORTHOPAEDICS AND SPORTS MEDICINE PC
Entity Type:Organization
Organization Name:CAPITAL ORTHOPAEDICS AND SPORTS MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SHAREHOLDER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:515-440-2676
Mailing Address - Street 1:12499 UNIVERSITY AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-8281
Mailing Address - Country:US
Mailing Address - Phone:515-440-2676
Mailing Address - Fax:515-440-2677
Practice Address - Street 1:12499 UNIVERSITY AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8281
Practice Address - Country:US
Practice Address - Phone:515-440-2676
Practice Address - Fax:515-440-2677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-16
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA207X00000X
IA26239207XS0106X
IA19337207XS0117X
IA33389207XX0005X
IA27587208100000X
IA377442086S0105X
IA00693213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Multi-Specialty
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the HandGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1932432457Medicaid
IA1932432457Medicaid