Basic Information
| Provider Information | |||||||||
| NPI: | 1649516717 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHO FLORIDA LLC | ||||||||
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| OtherOrganizationName: | GEORGIY BRUSOVANIK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 GLADES RD | ||||||||
| Address2: | SUITE 460 | ||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334316465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613001779 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7150 W 20TH AVE | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330165529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054675678 | ||||||||
| FaxNumber: | 3055037006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2012 | ||||||||
| LastUpdateDate: | 12/18/2012 | ||||||||
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| AuthorizedOfficialLastName: | TOCCI | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9544105194 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ORTHO FLORIDA. LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | MDR-4545 | HI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.