MEDICARE: CHARLOTTE ORTHOPAEDIC CLINIC PROFESSIONAL ASSOCIATION

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
1	207X00000X	Orthopaedic Surgery Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	DE0219	OTHER	FL	RAILROAD MEDICARE
6	DE0219	OTHER	FL	RR MEDICARE
8	K2675	OTHER	FL	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0886990001	OTHER	FL	PALMETTO
2	4639456	OTHER	FL	AETNA
3	1596302000	OTHER	FL	DEPT OF LABOR
4	77674	OTHER	FL	BLUE CROSS BLUE SHIELD
7	7323528-002	OTHER	FL	CIGNA-PAL

General Provider Information

NPI Number	:	1952350977
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHARLOTTE ORTHOPAEDIC CLINIC PROFESSIONAL ASSOCIATION

Provider Business Mailing Address
First Line	:	4161 TAMIAMI TRL
Second Line	:	UNIT 101
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33952-9204
Country	:	US
Telephone Number	:	941-625-0984
Fax Number	:	941-625-0877

Provider Business Practice Location Address
First Line	:	4161 TAMIAMI TRL
Second Line	:	UNIT 101
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33952-9204
Country	:	US
Telephone Number	:	941-625-0984
Fax Number	:	941-625-0877

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	MS. ELIZABETH RENEE MCLURE
Credential	:
Telephone Number	:	941-625-0984

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	08/05/2013

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Directions to “CHARLOTTE ORTHOPAEDIC CLINIC PROFESSIONAL ASSOCIATION ” Practice Location

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