=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699205815
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORTHOPAEDIC MEDICAL GROUP OF TAMPA BAY PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2017
-----------------------------------------------------
Last Update Date | 10/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2805 54TH AVE N STE 100
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33714-2414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-684-2663
-----------------------------------------------------
Fax | 813-658-6222
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 850001 DEPT 8272
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32885-8272
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-684-2663
-----------------------------------------------------
Fax | 813-441-7161
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD/PRESIDENT
-----------------------------------------------------
Name | SCOTT GOLDSMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 813-534-0102
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------