Provider Demographics
NPI:1861593436
Name:ORTHOPAEDIC AND SPORTS MEDICINE SPECIALIST
Entity type:Organization
Organization Name:ORTHOPAEDIC AND SPORTS MEDICINE SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:RADA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-443-9191
Mailing Address - Street 1:224 PECAN PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-3308
Mailing Address - Country:US
Mailing Address - Phone:318-443-9191
Mailing Address - Fax:318-443-4144
Practice Address - Street 1:224 PECAN PARK AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-3308
Practice Address - Country:US
Practice Address - Phone:318-443-9191
Practice Address - Fax:318-443-4144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty