Basic Information
| Provider Information | |||||||||
| NPI: | 1073058855 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ORTHO FLORIDA, LLC | ||||||||
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| OtherOrganizationName: | FLORIDA SPINE ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 751 PARK OF COMMERCE DR | ||||||||
| Address2: | STE 112 | ||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334873626 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5162 LINTON BLVD | ||||||||
| Address2: | STE 203 | ||||||||
| City: | DELRAY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334846567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614959511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2017 | ||||||||
| LastUpdateDate: | 01/03/2017 | ||||||||
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| AuthorizedOfficialLastName: | TRASK | ||||||||
| AuthorizedOfficialFirstName: | DANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 8137871128 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ORTHO FLORIDA, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery | 207XS0117X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
No ID Information.