Basic Information
| Provider Information | |||||||||
| NPI: | 1710363957 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPAEDIC MEDICAL GROUP OF TAMPA BAY PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 850001 DEPT 8272 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328858272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136842663 | ||||||||
| FaxNumber: | 8134417161 | ||||||||
| Practice Location | |||||||||
| Address1: | 4541 S DALE MABRY HWY | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136842663 | ||||||||
| FaxNumber: | 8138773017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2015 | ||||||||
| LastUpdateDate: | 12/30/2021 | ||||||||
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| AuthorizedOfficialLastName: | GOLDSMITH | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
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| AuthorizedOfficialTitleorPosition: | M.D. | ||||||||
| AuthorizedOfficialTelephone: | 8136842663 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 12/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 374193100 | 05 | FL | MEDICAID |