MEDICARE: FLORIDA SPORTS MEDICINE INSTITUTE INC

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	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	OS7217	FL

General Provider Information

NPI Number	:	1467621003
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FLORIDA SPORTS MEDICINE INSTITUTE INC

Provider Business Mailing Address
First Line	:	150 SOUTHPARK BLVD
Second Line	:	SUITE 102
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32086-5190
Country	:	US
Telephone Number	:	904-823-3764
Fax Number	:	904-429-0318

Provider Business Practice Location Address
First Line	:	4131 UNIVERSITY BLVD S
Second Line	:	SUITE 15
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-4326
Country	:	US
Telephone Number	:	904-854-4587
Fax Number	:	904-429-0318

Authorized Official
Title or Position	:	CEO
Name	:	MS. KAREN LYNN HASELTINE
Credential	:
Telephone Number	:	904-823-3764

Provider Enumeration Date	:	02/28/2008
Last Update Date	:	01/06/2010

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Directions to “FLORIDA SPORTS MEDICINE INSTITUTE INC ” Practice Location

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