1104956341 NPI number — TALLAHASSEE ORTHOPEDIC & SPORTS PHYSICAL THERAPY

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 1104956341 NPI number — TALLAHASSEE ORTHOPEDIC & SPORTS PHYSICAL THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TALLAHASSEE ORTHOPEDIC & SPORTS PHYSICAL THERAPY
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:
MADISON CLINIC
Provider Other Organization Name Type Code:
5
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:
1104956341
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 13269
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TALLAHASSEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32317-3269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-219-1520
Provider Business Mailing Address Fax Number:
850-219-1521

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
257 SW DADE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32340-2361
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-973-3316
Provider Business Practice Location Address Fax Number:
850-973-1261
Provider Enumeration Date:
03/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KNISLEY
Authorized Official First Name:
KENT
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
850-973-3316

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 883224200 . This is a "PARENT FACILITY MEDICAID ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 883224205 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1376593053 . This is a "PARENT FACILITY NPI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 106243801 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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