Provider Demographics
NPI:1417436726
Name:PROVIDENT ORTHOPEDIC AND SPORTS MEDICINE CENTER
Entity Type:Organization
Organization Name:PROVIDENT ORTHOPEDIC AND SPORTS MEDICINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:F
Authorized Official - Last Name:SHULER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-906-3621
Mailing Address - Street 1:801 MARSHALL FARMS RD
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-3316
Mailing Address - Country:US
Mailing Address - Phone:407-906-3621
Mailing Address - Fax:407-614-3171
Practice Address - Street 1:801 MARSHALL FARMS RD
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-3316
Practice Address - Country:US
Practice Address - Phone:407-906-3621
Practice Address - Fax:407-614-3171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-08
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL041584600Medicaid