Basic Information
| Provider Information | |||||||||
| NPI: | 1023539574 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ORTHO FLORIDA, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTH MIAMI WALK-IN ORTHOPEDICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 978766 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753978766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613001792 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5966 S DIXIE HWY STE 401 | ||||||||
| Address2: | |||||||||
| City: | SOUTH MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331435177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7864532667 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2017 | ||||||||
| LastUpdateDate: | 01/07/2020 | ||||||||
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| AuthorizedOfficialLastName: | TRASK | ||||||||
| AuthorizedOfficialFirstName: | DANE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8137871128 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ORTHO FLORIDA, LLC | ||||||||
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| NPICertificationDate: | 01/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PS0010X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Sports Medicine |
No ID Information.