Basic Information
| Provider Information | |||||||||
| NPI: | 1083870604 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST COAST MUSCULOSKELETAL INSTITUTE PL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14555 CORTEZ BLVD | ||||||||
| Address2: | |||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346136003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525564823 | ||||||||
| FaxNumber: | 3525564824 | ||||||||
| Practice Location | |||||||||
| Address1: | 14555 CORTEZ BLVD | ||||||||
| Address2: | |||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346136003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525564823 | ||||||||
| FaxNumber: | 3525564824 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2008 | ||||||||
| LastUpdateDate: | 04/15/2010 | ||||||||
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| AuthorizedOfficialLastName: | MOYNIHAN | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3525564823 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | ME101245 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | ME 101245 | 01 | FL | MEDICAL LICENSE | OTHER |