MEDICARE: JOHN PAUL VIDOLIN M D P A

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	45975	OTHER	FL	BC BS OF FLORIDA

General Provider Information

NPI Number	:	1336120484
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN PAUL VIDOLIN M D P A

Provider Business Mailing Address
First Line	:	STE 102
Second Line	:	836 SUNSET LAKE BLVD
City	:	VENICE
State	:	FL
Zip	:	34292-7555
Country	:	US
Telephone Number	:	941-497-1771
Fax Number	:	941-497-1860

Provider Business Practice Location Address
First Line	:	836 SUNSET LAKE BLVD
Second Line	:	STE 102
City	:	VENICE
State	:	FL
Zip	:	34292-7555
Country	:	US
Telephone Number	:	941-497-1771
Fax Number	:	941-497-1860

Authorized Official
Title or Position	:	CFO
Name	:	JOHN PAUL VIDOLIN
Credential	:	MD
Telephone Number	:	941-497-1771

Provider Enumeration Date	:	11/07/2005
Last Update Date	:	12/18/2009

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