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NPI Code Detail

MEDICARE: SPORTS MEDICINE INSTITUTE INTERNATIONAL LLC

MEDICARE: SPORTS MEDICINE INSTITUTE INTERNATIONAL LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207XX0005XSports Medicine (Orthopaedic Surgery) PhysicianME0037707FL

General Provider Information

NPI Number : 1366884496
Entity Type Code : Organization
Provider Name (Legal Business Name) : SPORTS MEDICINE INSTITUTE INTERNATIONAL LLC
Provider Business Mailing Address
First Line : 1925 DON WICKHAM DR
Second Line :
City : CLERMONT
State : FL
Zip : 34711-1915
Country : US
Telephone Number : 352-243-9700
Fax Number : 352-243-5795
Provider Business Practice Location Address
First Line : 1925 DON WICKHAM DR
Second Line :
City : CLERMONT
State : FL
Zip : 34711-1915
Country : US
Telephone Number : 352-243-9700
Fax Number : 352-243-5795
Authorized Official
Title or Position : PRESIDENT
Name : TRACEE LEIANN RAY
Credential : RN
Telephone Number : 352-243-9700
Provider Enumeration Date : 07/17/2013
Last Update Date : 12/10/2013

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Directions to “SPORTS MEDICINE INSTITUTE INTERNATIONAL LLC ” Practice Location

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