Provider Demographics
NPI:1275020414
Name:ORTHOPAEDIC MEDICAL GROUP OF TAMPA BAY PA
Entity Type:Organization
Organization Name:ORTHOPAEDIC MEDICAL GROUP OF TAMPA BAY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDSMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-684-2663
Mailing Address - Street 1:PO BOX 850001 DEPT 8272
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32885-8272
Mailing Address - Country:US
Mailing Address - Phone:813-684-2663
Mailing Address - Fax:813-441-7161
Practice Address - Street 1:10740 PALM RIVER RD STE 310
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-4577
Practice Address - Country:US
Practice Address - Phone:813-684-2663
Practice Address - Fax:813-654-1619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-13
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207X00000X
225100000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL374193100Medicaid