Healthcare Provider Details

I. General information

NPI: 1831521756
Provider Name (Legal Business Name): ORTHOPEDIC CENTER FOR SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2013
Last Update Date: 01/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 PARK PLACE BLVD SUITE A
DAVENPORT FL
33837-6858
US

IV. Provider business mailing address

105 PARK PLACE BLVD SUITE A
DAVENPORT FL
33837-6858
US

V. Phone/Fax

Practice location:
  • Phone: 863-421-7411
  • Fax: 863-547-9514
Mailing address:
  • Phone: 863-421-7411
  • Fax: 863-547-9514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME72924
License Number StateFL

VIII. Authorized Official

Name: MR. ROBERT MATHIS
Title or Position: ADMINISTRATOR
Credential:
Phone: 863-421-7411