Provider Demographics
NPI:1346341476
Name:FLORIDA SPORTS MEDICINE INSTITUTE INC
Entity Type:Organization
Organization Name:FLORIDA SPORTS MEDICINE INSTITUTE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:HASELTINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-823-3764
Mailing Address - Street 1:150 SOUTHPARK BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5190
Mailing Address - Country:US
Mailing Address - Phone:904-823-3764
Mailing Address - Fax:904-429-0318
Practice Address - Street 1:150 SOUTHPARK BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5190
Practice Address - Country:US
Practice Address - Phone:904-823-3764
Practice Address - Fax:904-429-0318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7217207XX0005X
FLME93573207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00728OtherBLUE CROSS GROUP
FLI22085Medicare UPIN
FLF38728Medicare UPIN
FLK0087Medicare ID - Type Unspecified