=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639177579
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED ORTHOPEDIC CENTER OF CHARLOTTE COUNTY, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2005
-----------------------------------------------------
Last Update Date | 10/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1641 TAMIAMI TRL SUITE 1
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33948-1042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-629-6262
-----------------------------------------------------
Fax | 941-629-1782
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1641 TAMIAMI TRL SUITE 1
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33948-1042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-629-6262
-----------------------------------------------------
Fax | 941-629-1782
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CORPORATE PRESIDENT
-----------------------------------------------------
Name | DALE A GREENBERG
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 941-629-6262
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------