=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821163270
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RADNOTHY ORTHOPAEDICS, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2006
-----------------------------------------------------
Last Update Date | 11/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2051 MAYO DRIVE
-----------------------------------------------------
City | TAVARES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32778
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-343-2171
-----------------------------------------------------
Fax | 352-343-1475
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2051 MAYO DRIVE
-----------------------------------------------------
City | TAVARES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32778
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-343-2171
-----------------------------------------------------
Fax | 352-343-1475
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN/OWNER
-----------------------------------------------------
Name | JON H. RADNOTHY
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 352-343-2171
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 056686
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------