1417943846 NPI number — HIGHLAND CENTER FOR ORTHOPEDICS & UPPER EXTREMITY SURGERY P A

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417943846 NPI number — HIGHLAND CENTER FOR ORTHOPEDICS & UPPER EXTREMITY SURGERY P A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HIGHLAND CENTER FOR ORTHOPEDICS & UPPER EXTREMITY SURGERY P A
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HIGHLAND CENTER FOR ORTHOPAEDICS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417943846
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2161 E COUNTY ROAD 540A
Provider Second Line Business Mailing Address:
#286
Provider Business Mailing Address City Name:
LAKELAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33813-3794
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-398-0039
Provider Business Mailing Address Fax Number:
863-709-1060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3317 US HIGHWAY 98 S STE 9
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33803-8316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-709-8777
Provider Business Practice Location Address Fax Number:
863-709-1060
Provider Enumeration Date:
09/21/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JURBALA
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
863-709-8777

Provider Taxonomy Codes

  • Taxonomy code: 207XS0114X , with the licence number:  ME70116 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208100000X , with the licence number: ME99610 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10D2004873 . This is a "CLIA LICENSE 22411 HWY 27 LAKE WALES" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 10D2004874 . This is a "CLIA LICENSE FOR 3317 US HWY 98 SOUTH STE 9" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 018129700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".