Provider Demographics
NPI:1417251034
Name:STEVEN KNEZEVICH, M.D., P.A.
Entity Type:Organization
Organization Name:STEVEN KNEZEVICH, M.D., P.A.
Other - Org Name:NORTHSIDE ORTHOPAEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-960-1655
Mailing Address - Street 1:3820 NORTHDALE BLVD.,
Mailing Address - Street 2:SUITE 105A
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-1834
Mailing Address - Country:US
Mailing Address - Phone:813-960-1655
Mailing Address - Fax:813-960-3681
Practice Address - Street 1:3820 NORTHDALE BLVD.,
Practice Address - Street 2:SUITE 105A
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-1834
Practice Address - Country:US
Practice Address - Phone:813-960-1655
Practice Address - Fax:813-960-3681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-23
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME60554207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL056274200Medicaid
FL056274200Medicaid
FLE94149Medicare UPIN