Provider Demographics
NPI:1013376490
Name:CARROLLTON ORTHOPAEDIC CLINIC PC
Entity Type:Organization
Organization Name:CARROLLTON ORTHOPAEDIC CLINIC PC
Other - Org Name:CARROLLTON ORTHOPAEDIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:GILBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-755-0693
Mailing Address - Street 1:311 PARK PLACE BLVD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-4904
Mailing Address - Country:US
Mailing Address - Phone:727-755-0693
Mailing Address - Fax:
Practice Address - Street 1:204 ALLEN MEMORIAL DR STE 102
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:GA
Practice Address - Zip Code:30110-2063
Practice Address - Country:US
Practice Address - Phone:727-755-0679
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-15
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038964333600000X
3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000104427Medicaid
2158424OtherPK