Healthcare Provider Details

I. General information

NPI: 1700100179
Provider Name (Legal Business Name): WESTCHASE SPORTS MEDICINE ORTHOPAEDICS, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2010
Last Update Date: 03/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11301 COUNTRYWAY BLVD
TAMPA FL
33626-2610
US

IV. Provider business mailing address

11301 COUNTRYWAY BLVD
TAMPA FL
33626-2610
US

V. Phone/Fax

Practice location:
  • Phone: 813-855-8450
  • Fax: 813-855-7540
Mailing address:
  • Phone: 813-855-8450
  • Fax: 813-855-7540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberME100433
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberOS8857
License Number StateFL

VIII. Authorized Official

Name: DR. MALCOLM CHRISTOPHER MACLAREN
Title or Position: PARTNER
Credential: D.O.
Phone: 813-855-8450