Basic Information
| Provider Information | |||||||||
| NPI: | 1760979140 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOPAEDIC MEDICAL GROUP OF TAMPA BAY PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ORTHOPAEDIC MEDICAL GROUP PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 615 VONDERBURG DR | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335115972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136842663 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10740 PALM RIVER RD STE 310 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336194577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136842663 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2018 | ||||||||
| LastUpdateDate: | 07/18/2019 | ||||||||
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| AuthorizedOfficialLastName: | REID | ||||||||
| AuthorizedOfficialFirstName: | TARYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 8135340102 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ORTHOPAEDIC MEDICAL GROUP OF TAMPA BAY | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 208100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 374193100 | 05 | FL | MEDICAID |