Provider Demographics
NPI:1073068458
Name:ORTHOPAEDIC CLINIC OF DAYTONA BEACH PA
Entity Type:Organization
Organization Name:ORTHOPAEDIC CLINIC OF DAYTONA BEACH PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:GILLESPY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-255-4596
Mailing Address - Street 1:1075 MASON AVENUE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-4611
Mailing Address - Country:US
Mailing Address - Phone:386-255-4596
Mailing Address - Fax:386-258-3561
Practice Address - Street 1:1890 LPGA BOULEVARD
Practice Address - Street 2:SUITE 240
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-7131
Practice Address - Country:US
Practice Address - Phone:386-255-4596
Practice Address - Fax:386-258-3561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-16
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207X00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00027OtherMEDICARE
FL036096100Medicaid