Provider Demographics
NPI:1144644857
Name:ORTHOPEDIC CARE PHYSICIAN NETWORK LLC
Entity type:Organization
Organization Name:ORTHOPEDIC CARE PHYSICIAN NETWORK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNELISSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-344-3535
Mailing Address - Street 1:15 ROCHE BROTHERS WAY
Mailing Address - Street 2:
Mailing Address - City:NORTH EASTON
Mailing Address - State:MA
Mailing Address - Zip Code:02356-1000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:675 PARAMOUNT DR
Practice Address - Street 2:SUITE 205
Practice Address - City:RAYNHAM
Practice Address - State:MA
Practice Address - Zip Code:02767-5416
Practice Address - Country:US
Practice Address - Phone:508-828-5848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-17
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA7021150003Medicare NSC