Provider Demographics
NPI:1003064841
Name:ROBERTS ORTHOPAEDIC CLINIC PA
Entity Type:Organization
Organization Name:ROBERTS ORTHOPAEDIC CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SONIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAFFEEULLAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-292-8992
Mailing Address - Street 1:453 N KIRKMAN RD STE 201
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811-1109
Mailing Address - Country:US
Mailing Address - Phone:407-292-8992
Mailing Address - Fax:407-292-6114
Practice Address - Street 1:453 N KIRKMAN RD STE 201
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32811-1109
Practice Address - Country:US
Practice Address - Phone:407-292-8992
Practice Address - Fax:407-292-6114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-05
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0041010207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL47628OtherPTAN
FL069105400Medicaid
FL069105400Medicaid