Healthcare Provider Details

I. General information

NPI: 1346341476
Provider Name (Legal Business Name): FLORIDA SPORTS MEDICINE INSTITUTE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 01/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 SOUTHPARK BLVD SUITE 102
ST AUGUSTINE FL
32086-5190
US

IV. Provider business mailing address

150 SOUTHPARK BLVD SUITE 102
ST AUGUSTINE FL
32086-5190
US

V. Phone/Fax

Practice location:
  • Phone: 904-823-3764
  • Fax: 904-429-0318
Mailing address:
  • Phone: 904-823-3764
  • Fax: 904-429-0318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberME93573
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberOS7217
License Number StateFL

VIII. Authorized Official

Name: MS. KAREN HASELTINE
Title or Position: C.E.O.
Credential:
Phone: 904-823-3764