1861761256 NPI number — ORTHOMED PAIN & SPORTS MEDICINE

Table of content: (NPI 1861761256)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861761256 NPI number — ORTHOMED PAIN & SPORTS MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORTHOMED PAIN & SPORTS MEDICINE
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:
Provider Other Organization Name Type Code:
6
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:
1861761256
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4071 BEE RIDGE RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
SARASOTA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34233-2550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-371-7171
Provider Business Mailing Address Fax Number:
941-371-7474

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
389 COMMERCIAL CT
Provider Second Line Business Practice Location Address:
SUITE D2
Provider Business Practice Location Address City Name:
VENICE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34292-1617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-485-1890
Provider Business Practice Location Address Fax Number:
941-485-1783
Provider Enumeration Date:
12/14/2011

Additional Information

Authorized Official

Authorized Official Last Name:
COLE
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
941-485-1890

Provider Taxonomy Codes

  • Taxonomy code: 2081P2900X , with the licence number:  OS8697 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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