Provider Demographics
NPI:1285860007
Name:TAMPA BAY ORTHOPAEDIC & SPINE, LLC
Entity Type:Organization
Organization Name:TAMPA BAY ORTHOPAEDIC & SPINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-501-2347
Mailing Address - Street 1:1811 N BELCHER RD
Mailing Address - Street 2:SUITE H-2
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33765-1433
Mailing Address - Country:US
Mailing Address - Phone:727-672-4637
Mailing Address - Fax:727-724-6377
Practice Address - Street 1:1811 N BELCHER RD
Practice Address - Street 2:SUITE H-2
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765-1433
Practice Address - Country:US
Practice Address - Phone:727-672-4637
Practice Address - Fax:727-724-6377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-08
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8857207X00000X
FLME48335208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty