Basic Information
Provider Information | |||||||||
NPI: | 1700323367 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ORTHO FLORIDA, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FLORIDA BONE AND JOINT SPECIALISTS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 751 PARK OF COMMERCE DR | ||||||||
Address2: |   | ||||||||
City: | BOCA RATON | ||||||||
State: | FL | ||||||||
PostalCode: | 334873626 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5613001792 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1040 GULF BREEZE PKWY | ||||||||
Address2: | STE 209 | ||||||||
City: | GULF BREEZE | ||||||||
State: | FL | ||||||||
PostalCode: | 325617809 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8509163700 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/20/2017 | ||||||||
LastUpdateDate: | 01/23/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TRASK | ||||||||
AuthorizedOfficialFirstName: | DANE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | COO | ||||||||
AuthorizedOfficialTelephone: | 8137871128 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ORTHO FLORIDA, LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0106X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery |
No ID Information.