=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811404155
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE CENTER FOR BONE AND JOINT DISEASE, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2018
-----------------------------------------------------
Last Update Date | 01/09/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16506 POINTE VILLAGE DR STE 109
-----------------------------------------------------
City | LUTZ
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33558-5255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-605-3808
-----------------------------------------------------
Fax | 352-503-2361
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7544 JACQUE RD
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34667-7162
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-697-2200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING DEPARTMENT
-----------------------------------------------------
Name | GRACE NICOLE MARTINO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 727-857-4397
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------