Healthcare Provider Details

I. General information

NPI: 1013376490
Provider Name (Legal Business Name): CARROLLTON ORTHOPAEDIC CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2016
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 ALLEN MEMORIAL DR STE 102
BREMEN GA
30110-2063
US

IV. Provider business mailing address

311 PARK PLACE BLVD SUITE 500
CLEARWATER FL
33759-4904
US

V. Phone/Fax

Practice location:
  • Phone: 727-755-0679
  • Fax:
Mailing address:
  • Phone: 727-755-0693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number038964
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JAMES GILBERT
Title or Position: CFO
Credential:
Phone: 727-755-0693