=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649345893
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MUSCULOSKELETAL INSTITUTE CHARTERED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 909 N DALE MABRY HWY
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33609-1251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-287-9370
-----------------------------------------------------
Fax | 813-558-6185
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13020 N TELECOM PKWY
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33637-0925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-978-9700
-----------------------------------------------------
Fax | 813-972-2078
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ROY W SANDERS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 813-978-9700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------