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General NPI Number Information
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NPI Number | 1982815650
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Entity Type | Organization
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Legal Business Name | ORTHOPEDIC SURGERY AND SPORTS MED
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Dates
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Enumeration Date | 05/24/2007
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Last Update Date | 09/10/2007
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Provider Practice Location Address
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Address Line | 1275 W GRANADA BLVD SUITE 3B
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City | ORMOND BEACH
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State | FL
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Zip | 32174-8259
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Country | US
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Telephone | 386-672-7850
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Fax |
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Provider Business Mailing Address
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Address Line | 1275 W GRANADA BLVD SUITE 3B
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City | ORMOND BEACH
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State | FL
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Zip | 32174-8259
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | BILLING MANAGER
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Name | MICHELLE CAVANAUGH
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Credential |
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Telephone | 386-274-5712
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207XX0005X
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Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
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License Number | ME53344
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License Number State | FL
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