Provider Demographics
NPI:1548353162
Name:ORTHOPEDIC SURGERY AND SPORTS MEDICINE
Entity type:Organization
Organization Name:ORTHOPEDIC SURGERY AND SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:FERRIS
Authorized Official - Suffix:SR
Authorized Official - Credentials:DO
Authorized Official - Phone:586-286-0670
Mailing Address - Street 1:43281 COMMONS DRIVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038
Mailing Address - Country:US
Mailing Address - Phone:586-286-0670
Mailing Address - Fax:
Practice Address - Street 1:43281 COMMONS DRIVE
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038
Practice Address - Country:US
Practice Address - Phone:586-286-0670
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJF004878207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI119353OtherGREAT LAKES HEALTH CARE
MI4622217OtherAETNA
MINC010517OtherMCARE
MI4622217OtherAETNA