=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104819499
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PENSACOLA BONE & JOINT CLINIC PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2005
-----------------------------------------------------
Last Update Date | 08/20/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5147 N 9TH AVE SUITE 110
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32504-8771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-479-7229
-----------------------------------------------------
Fax | 850-479-7250
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5147 N 9TH AVE SUITE 110
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32504-8771
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-479-7229
-----------------------------------------------------
Fax | 850-479-7250
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JOHN THEODORE DEJONG
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 850-479-7229
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | L1829
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | ME0053867
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------