=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306892609
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE CLEARWATER ORTHOPAEDIC ASC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2006
-----------------------------------------------------
Last Update Date | 01/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2238 DREW ST
-----------------------------------------------------
City | CLEARWATER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33765-3305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-724-5653
-----------------------------------------------------
Fax | 727-797-5214
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2238 DREW ST
-----------------------------------------------------
City | CLEARWATER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33765-3305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-724-5653
-----------------------------------------------------
Fax | 727-797-5214
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP/COO
-----------------------------------------------------
Name | JEFFREY L STOCKARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-377-5353
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------