Healthcare Provider Details

I. General information

NPI: 1801506571
Provider Name (Legal Business Name): STAR ORTHOPEDICS AND SPINE OF TAMPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2022
Last Update Date: 12/02/2022
Certification Date: 12/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10676 BLOOMINGDALE AVE # 3
RIVERVIEW FL
33578-4292
US

IV. Provider business mailing address

10676 BLOOMINGDALE AVE # 3
RIVERVIEW FL
33578-4292
US

V. Phone/Fax

Practice location:
  • Phone: 813-302-1714
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State

VIII. Authorized Official

Name: HILLARY KOERNER
Title or Position: OFFICE MANAGER
Credential:
Phone: 561-908-3200