Provider Demographics
NPI:1326299306
Name:NORTH TAMPA ORTHOPAEDICS SPORTS MEDICINE PA
Entity Type:Organization
Organization Name:NORTH TAMPA ORTHOPAEDICS SPORTS MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:JASON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-683-0007
Mailing Address - Street 1:12212 CORTEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-2631
Mailing Address - Country:US
Mailing Address - Phone:352-683-0007
Mailing Address - Fax:
Practice Address - Street 1:120 MEDICAL BLVD
Practice Address - Street 2:SUITE 109
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34609-0220
Practice Address - Country:US
Practice Address - Phone:352-683-0007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-08
Last Update Date:2013-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0074687207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6720260001OtherMEDICARE PTAN